Counseling Veterans Applying for Service Connection Status for Mental Health Conditions

Veterans with mental health conditions that were caused or aggravated by military service may be eligible for service-connected disability benefits awarded by the Department of Veterans Affairs (VA) (1). Service connection confers important benefits, including a monthly stipend, a range of VA services, preferential hiring for federal jobs, and survivor benefits (2). As of 2013, approximately 3.5 million of the nation’s 22 million veterans had service connection status (1), with approximately 650,000 service connected for posttraumatic stress disorder (PTSD) (3).

Veterans often find the service connection process complicated and confusing (2). Thus it is not surprising that they frequently develop beliefs about service connection that may not be accurate and could interfere with treatment. Veterans may feel stressed by the sensitive issues discussed, financial consequences of the claim decision, disability label, or application process, and they may sense that the VA is contesting the claim (2). Veterans appreciate clinicians who are conversant in military culture and issues (4), and knowing about service connection is one way that clinicians can demonstrate this familiarity.

Unfortunately, clinicians often view service connection issues as impediments to treatment. Surveyed VA PTSD clinicians reported perceiving veterans who were applying for service connection as less engaged in treatment than veterans who were not applying, and most believed that service connection claims had a negative impact on treatment (5). Despite contrary evidence (6), some clinicians have expressed concerns that veterans will drop out of treatment once they are awarded benefits.

We believe that discussing service connection claims with veterans can enhance therapy by addressing an important and distressing issue. To prepare this Open Forum, we reviewed our personal clinical experiences, consulted with a range of experienced clinicians, and reviewed available research.

Primer on Service Connection

Veterans can apply for service connection right before or any time after leaving active duty. The Veterans Benefits Administration (VBA) processes service connection claims and is separate from the Veterans Health Administration (VHA), which provides treatment to eligible veterans. VBA typically requests compensation and pension (C&P) evaluations by credentialed examiners. The examiner reviews military records, medical records, and other submitted materials and then conducts an evaluation and writes a report describing diagnoses, functional limitations, and likelihood that symptoms are related to military service (7).

VBA adjudicators review results, and conditions that are judged more likely than not to have been caused or exacerbated by military service are deemed to be service connected (1). VBA estimates the degree of associated disability, ranging from 0% to 100%. Approximately, 2% of single disabilities are rated at the 100% level, and 10% of veterans who receive service connection have a combined disability rating (that is, for more than one condition) of 100% (1). It can take over a year for an initial claim to be processed. VBA can reevaluate veterans every two to five years for nonpermanent conditions (38 CFR§3.327), but most reevaluations are initiated by veterans seeking an increase in service-connected disability ratings (1). Service connection provided for ten years cannot be revoked unless the original claim was fraudulent (38 CFR§3.957).

VA service connection differs from Social Security disability status in that eligibility and disability rating (percentage) for service connection are not based on an inability to work but rather on the average impairment in earning capacity that the condition typically causes (38 CFR§4.15). Occupational and social impairment are considered for service connection (38 CFR§4.126); however, employed veterans can receive service connection for conditions that may prevent an average person from working. Although receipt of service-connected disability benefits is sometimes seen as a disincentive to work for pay, veterans can work without losing benefits (1). Infrequently, veterans are found to be “individually unemployable” (IU), a separate designation assigned to veterans whose combined ratings are not at the 100% level but who are deemed unable to engage in substantial work. These veterans may have an incentive to avoid employment, because the IU designation, which provides benefits at the 100% level, can be stopped after one year of gainful employment (38 CFR§4.16).

Beliefs to Address

We recommend that clinicians have some understanding of the C&P process and know the location where service connection claims issues are addressed. Below we discuss several possible treatment-interfering beliefs about service connection that clinicians can address by using accurate information and good therapeutic skills.

“My VA clinician directly influences my service connection determination.”

As noted, decisions about service connection are made by VBA, and clinicians other than C&P examiners do not have direct influence over the process. Providers should explain that C&P examiners conduct their own evaluation and have access to military records that clinicians might not (8). Some veterans come to the VA asking for a “PTSD evaluation,” and it becomes clear only after they are referred to a clinician that the veteran wants an evaluation for service connection and does not want to initiate treatment. We recommend that clinicians clarify and differentiate their involvement in assessment, treatment, and recovery from the C&P examiner’s role in assessing a claim.

“Progress notes determine service connection.”

Veterans are often aware that treatment records are reviewed by C&P examiners and adjudicators (8). Veterans may believe that they will receive service connection status if VA providers document specific diagnoses or that they cannot get service connection status if certain diagnoses are not in their record. Veterans may worry that if issues such as substance abuse are documented, a C&P examiner will attribute impairment to substance use and not to a condition for which they can be awarded service connection status. Veterans might be concerned about what to discuss in treatment and how it will be documented, which may lead to reluctance to disclose information or engage in treatment.

Clinicians should not cede control of documentation. For example, clinicians should not document material only because a veteran suggests it will support a claim. Such a step interferes with therapy by making it a component of the service connection process. If a veteran believes his or her service connection claim is not being adequately supported or was unfairly denied, we recommend steering the veteran to a third-party advocacy organization for assistance.

“I can get service connected only for PTSD.”

PTSD was identified as one of the “signature injuries” of the Iraq and Afghanistan conflicts, highlighted regularly in news, books, and films. Veterans may believe that PTSD is the only mental health condition for which service connection status is awarded, and veterans service organizations (VSOs) may recommend filing for service connection on the basis of PTSD (9). We recommend informing veterans that C&P examiners assess for other diagnosable conditions in addition to PTSD (7). It is important to reassure veterans that their service could have had a profound impact on them—and in compensable ways—even if they do not have PTSD.

“C&P examinations will be like a therapy session.”

Mental health C&P examinations are typically conducted at VHA health care facilities, usually by psychologists or psychiatrists. Veterans may go into the examination expecting it to be like a first session with a therapist. However, C&P examinations are forensic evaluations; the assessor is focused on collecting information about sensitive issues under time constraints, as opposed to alleviating distress (2,8). Thus veterans can feel interrogated. When asked about his C&P evaluation, a veteran we treat stated, “I hated it—I felt like I was being judged.” Another stated, “[The examiner] had his own agenda, and it had nothing much to do with any help for me.” We recommend differentiating the examination from therapy and explaining that the purpose of C&P examinations is for evaluation only.

“Service connection means I am ‘crazy.’”

Partly because of shame and embarrassment, many civilians do not seek professional help for mental health conditions or wait years to do so (10). Although stigma associated with service connection status appears to have decreased recently (11), veterans may delay or avoid applying for service connection or initiating treatment for similar reasons, especially because military culture places a high value on emotional strength and mental toughness (12). Clinicians should address veterans’ reservations about treatment, explain what therapy is (intended to help improve quality of life and alleviate symptoms) and what it is not (making someone “soft”), and explore fears about treatment.

“Service connection will cause me to lose my job/not get hired.”

Military personnel hold high-stress jobs, often with weapons access. Therefore, personnel with mental health conditions may be forced to undergo an evaluation of fitness for duty and can be discharged from the military if deemed unfit (4). Veterans may worry about how being seen as unfit, receiving service connection status, or engaging in treatment might affect military status or civilian employment. One veteran explained that he waited to apply because “I was told I could never get a job in law enforcement if I am service connected for PTSD.” Indeed, applicants for law enforcement positions may be asked whether they have “disabilities” and could have their military records reviewed.

The relationship between work and service connection is complex. Clinicians should explain that veterans can work and continue to receive service-connected disability benefits. In fact, VA encourages work, education, and recovery, which is evidenced by preferential hiring for certain federal jobs of veterans with service-connected disabilities, vocational rehabilitation with stipends for veterans with service-connected disabilities, and free priority health care for service-connected conditions (1,2).

“Not being awarded service connection means my service is not respected.”

Some veterans report that they applied for service-connected disability compensation in order to show what they had been through or to settle a grievance with the military (9).Veterans may view service connection status as validation of experiences or the distress those experiences caused, and rejection of a claim may feel like a denial of the veteran’s military experiences or symptoms.

Veterans may believe that higher ratings are indicative of having been braver, contributed more, or been exposed to more danger, when in fact they mean none of these things. Clinicians should help veterans distinguish between their rating and their service. Feeling that one deserves a higher rating may indicate more general feelings to be addressed in treatment—feeling unappreciated or wanting people to understand how difficult serving in the military or its aftermath has been. Service connection ratings are for symptoms and impairment (2), not for service, risk, or heroism.

“Not being awarded service connection means people don’t believe me.”

Despite equivocal evidence (13), the lay press, assorted advocacy groups, and some researchers emphatically state that veterans overreport symptoms to further their service connection claims. Some veterans get advice from VSO representatives who believe that the service connection process is capricious and adversarial and punishes veterans for honesty (14).

Ironically, C&P examiners do not suspect high rates of overreporting. A survey of C&P examiners found that approximately 25% believed at least 15% of veterans exaggerated PTSD symptoms (15), but the same proportion, 25%, believed that at least 15% underreported their symptoms. Claims are rejected for numerous reasons, including insufficient documentation, no diagnosis, or insufficient evidence that a condition is service related. Veterans may spend months or years completing the burdensome service connection evaluation process, during which time they may become increasingly convinced that they should receive a high service-connected disability rating. In our experience, many veterans experience a rejection of a claim as an indication that “the VA” does not believe their report of military experiences, symptoms, or distress. Clinicians should listen for indications that a compensation-seeking veteran feels distrusted or connects rejection of a claim to dynamics described in the popular press and recognize these as legitimate concerns. We recommend discussing the tension between the goals of the veteran (presentation of symptoms) and the examiner (critically gathering information and asking follow-up questions to determine a statement’s accuracy and how it should be weighed).

Conclusions

Ideas about service connection often arise in the course of treatment and can affect whether veterans seek care, talk openly to providers, and follow providers’ suggestions, resulting in a situation in which compensation claims and therapy have an impact on each other. For most issues raised in this Open Forum, we recommend a consistent approach. First, encourage open discussions of service connection. Second, validate veterans’ perspectives on issues raised. Third, offer information veterans may not have considered. Addressing service connection issues requires judgment. We are not advocating raising these issues when doing so would impede addressing more important treatment concerns or when a veteran does not want to discuss them.

Service connection can affect problems related to living with chronic conditions. Veterans often face complicated questions: How will I obtain money if I am too ill to work? How should I explain my condition to people to get the resources I need? What if they are skeptical of my explanation? For many veterans, exploring issues related to service connection is of immediate practical importance and more general value in coming to terms with the aftermath of their service.