Jim, I wanted to share with you some of my recent research, and I hope that you will in turn share

it with your readers. The attitude of VA Rating Officers, to include all persons who may come in contact with a veteran or a veterans claim is governed by 38 U.S.C. 4.23 Attitude of Rating Officers.1 Unfortunately this is not always followed. For example, on May 28, 2008 in VCS, et al. v Peake (Shinseki) the court was made aware of an email filed by Norma Perez a veterans health PTSD coordinator. That email read:Subject: Suggestion Given that we are having more and more compensation seeking veterans, Id like to suggest that you refrain from giving a diagnosis of PTSD straight out. Consider a diagnosis of Adjustment Disorder R/O PTSD. Also there have been some incidence where a veteran has a C&P is not given a diagnosis of PTSD, then the veteran comes here and we give the diagnosis, and the veteran appeals the case based on our assessment. Just a suggestion for the reasons listed above.2 This email was validated by the Department of Veterans Affairs council as genuine. What followed was a firestorm of political debate and inquiry in Washington D.C. about the apparently now substantiated allegation that VHA mental health professionals where stacking the deck against veterans meritorious claims for service connected benefits. Unfortunately, the treatment of Compensation Seeking as pathology is sadly not new. It has been the subject of clinical research since at least 19963. More to the point it did not end with the controversy and congressional hearings of 2008. Rather it has continued to the present year.4 The concept of Compensation Seeking as pathology has been partially carried forward, and partially denounced by the Best Practice Manual for Posttraumatic Stress Disorder (PTSD) Compensation and Pension Examinations.5. It reads on page 7:

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38 U.S.C. 4.23 Attitude of Rating Officers VCS, et al. v Peake (Shinseki) , et al Case No. 07-03758 Document 231 (USDC ND Cal 2008) 3 Compensation seeking status and psychometric assessment of combat veterans seeking treatment for PTSD. Frueh BC, Smith DW, Barker SE. J Trauma Stress. 1996 Jul;9(3):427-39 4 Why are Iraq and Afghanistan War veterans seeking PTSD disability compensation at unprecedented rates? McNally RJ, Frueh BC.J Anxiety Disord. 2013 Jun;27(5):520-6. doi: 10.1016/j.janxdis.2013.07.002. Epub 2013 Jul 26. 5 Best Practice Manual for Posttraumatic Stress Disorder (PTSD) Compensation and Pension Examinations. Watson P et al, Compensation ad Pension Service Veterans Benefits Administration

There has been evidence to suggest that compensation-seeking veterans endorse higher levels of psychopathology across measures and produce elevated validity indices on the MMPI and MMPI-2 as compared to non-compensation seeking veterans (Smith & Frueh, 1996; Frueh & Kinder, 1994). Sample sizes in these studies, however, are small, and clinicians were not correlating scores on the MMPI with collateral sources of data suggestive of overreporting. Even in non-compensation-seeking settings, the preponderance of evidence suggests that people with PTSD report significantly higher subjective distress than those without PTSD. This neutral response to the concept of the Compensation-Seeking veteran is starkly contrasted by the National Center for PTSD publication PTSD Research Quarterly 6 This publication referenced the Compensation-Seeking Veteran throughout. That VA funded publication of the National Center for PTSD featured abstracts from 19 professionally published and well circulated journal articles that seek to pathologize veterans for seeking their rights under Federal Law and Regulation. An additional ten articles on the topic are cited in journal footnotes. In a 2005 article published by the Journal of Military Medicine, and conducted by the Minneapolis VAMC it was concluded that VA disability benefits for PTSD reduced odds of impoverishment for psychiatrically ill veterans. This effect appeared to be especially important for African American veterans and for veterans self-identifying as disabled.7. Also a 2011 DVA Health Services Research and Development Service national meeting had as one of its featured presentations a paper titled Treatment Expectations, CompensationSeeking Status, and Therapeutic Alliance in a Sample of Military Veterans with PTSD 8 that was generated by the cornerstone of the DVAs PTSD research arm at Palo Alto, California. This article implied that veterans who seek to overcome the financial hardships of potential poverty and homelessness by applying for veterans disability benefits lack a strong alliance with treatment providers. Compare the above allegation that the compensation seeking veteran lacks a clinical alliance with the mental health community with the following excerpt from Post-Traumatic Stress Disorder Implications for Primary Care9 which is a VA published independent study course for primary care doctors.

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PTSD Disability Assessment PTSD Research Quarterly 2011; 22(4) Mitigating effect of Department of Veterans Affairs disability benefits for post-traumatic stress disorder on low income. Murdoch M, van Ryn M, Hodges J, Cowper D Mil Med. 2005 Feb;170(2):137-40 8 Treatment Expectations, Compensation-Seeking Status, and Therapeutic Alliance in a Sample of Military Veterans with PTSD 9 Post-Traumatic Stress Disorder Implications for Primary Care

Even when the veteran is successful in his or her pursuit of PTSD disability benefits, the process of obtaining such benefits can be extremely stressful (e.g., Eldridge, 1991). As in criminal proceedings, victims must recount their traumatic experiences to multiple people, all of whom serve in a forensic capacity. This repeated revisiting of the veterans traumatic experiences in itself may exacerbate PTSD and lead to acute decompensation. The patient may find it particularly devastating, if the claim is denied. Primary care providers should counsel their patients about this possibility and should encourage them to establish a stable, therapeutic relationship with a mental health provider before the veteran pursues a disability claim. Since veterans physical symptoms also may flare during this time because of stress, primary care providers should consider offering more frequent follow-up visits during the veterans C&P process. (page 71-72 underling added) According to the Government Accountability Office, VHA wait times for Mental Health Appointments are both unreliable and unacceptably long.10 See (GAO-13-130). But it is important to note that the veteran isnt being asked to wait to file for benefits until after they have a mental health appointment. Rather the veteran is being asked to wait to file until after they have established a Stable therapeutic relationship. What then is a Stable therapeutic relationship? Does it involve trust, closeness, communication, and problem solving? Certainly. However, according to the National Center for PTSDs own website11, lack of trust, lack of closeness in relationships, poor communication, and poor collaborative problem solving are hallmark symptoms of PTSD. Rhetorically, then, isnt VHA policy telling the veteran, You want to file a claim for PTSD to resolve your financial or homelessness problem? Whoa! Hold on there. Wait until after youre cured. In Cushman v. Shinseki, 576 F.3d 1290, 1298 (Fed. Cir. 2009)12 it was held that veterans have a vested property interest in their veterans disability claims. As such access to VA disability claims is protected by the 5th Amendment to the US Constitution, obstruction of which creates its own issues. Respectfully, Eric Lee Hughes

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GAO-13-130 http://www.ptsd.va.gov/public/pages/ptsd-and-relationships.asp 12 Cushman v. Shinseki, 576 F.3d 1290, 1298 (Fed. Cir. 2009)