Thursday, July 15, 2010
The Department of Veterans' Affairs has just eased the rules by which veterans can document stressors contributing to PTSD. The new regulations will lead to more disability claims and are applicable to all veterans. We explore the ramifications of the new regulations and what treatment is available for veterans in San Diego.
MAUREEN CAVANAUGH (Host): It's understood that veterans coming home from war have most likely been psychologically changed by the experience. But for some veterans, that change can have devastating and long-lasting effects. This week, the Veteran's Administration announced it's relaxing the burden on vets who are seeking benefits for Post Traumatic Stress Disorder. Not everyone is in favor of the changes. Some say it will increase the number of fraudulent claims. But most veterans groups are applauding the new rules as an increased commitment from the VA to address the emotional wounds suffered by soldiers of America's wars. I’d like to introduce my guests. Phil Landis is president and CEO of Veterans' Village, San Diego. Good morning, Phil.
PHIL LANDIS (President/CEO, Veterans' Village, San Diego): Good morning. How are you this morning?
CAVANAUGH: Thank – I’m very well. Thanks for being with us.
LANDIS: It’s my pleasure.
CAVANAUGH: And Dr. Arnold Gass is director of External Medical Services of Veterans' Healthcare Systems, San Diego. Dr. Gass, good morning.
DR. ARNOLD GASS (Director, External Medical Services, Veterans' Healthcare System, San Diego): Good morning, Maureen.
CAVANAUGH: Now, we’d like to invite our listeners to join the conversation. If you or someone in your family has suffered or has become disabled because of PTSD, if you would tell us your story, if you’d like to share your story, we would like to hear it. Or if you have questions about the new VA rules, give us a call at 1-888-895-5727, that’s 1-888-895-KPBS. So, Phil, let’s start right into it. Describe for us, if you would, the new regulations that the Department of Veterans Affairs has put into place for vets who are seeking disability benefits for PTSD.
LANDIS: Well, as I understand the relaxation of the rules apply to the nexus, that linkage between a stressor event and a diagnosis of PTSD. In the past, given certain other circumstances, i.e. a purple heart, which indicated that you were wounded in battle, a claimant for Post Traumatic Stress had to develop or prove a specific incident. And those are the rules primarily that have been relaxed.
CAVANAUGH: Right. So it’s my understanding that you sort of had to say, well, this happened to me in battle. I remember this particular incidence which I believe caused my Post Traumatic Stress Disorder. You had to bring in some sort of either evidence or memory of a specific event.
LANDIS: Well, the memory wasn’t enough.
LANDIS: You had to provide documentation that, in fact, what you indicated did, in fact, happen and that you were there at that time.
CAVANAUGH: Now you still have to be diagnosed by a doctor at the Veterans Administration, right?
LANDIS: Well, that’s correct. That really isn’t much of a change. The process requires that the claimant, the veteran, go through an evaluation, and part of that evaluation is being evaluated by a psychiatrist.
CAVANAUGH: Now, do you think, Phil, these new regulations might mean that the definition of combat is changing for the VA?
LANDIS: Well, I think the definition of combat is combat. I think the definition of what it means to be in a combat theater where you were subjected to combat stressors, that’s somewhat new. You know, in the current generation of conflicts in both Afghanistan and Iraq, you don’t necessarily have to be in a front line combat unit to be exposed to the horrendous stress of horrors of a combat event.
CAVANAUGH: In fact, the head of the VA, Mr. Shinseki, has said that you – just being in a war zone is a stressor.
LANDIS: Well, that’s correct. My generation was the Vietnam generation and, you know, you could be a truck driver or you could be a cook back in a rear eschelon base and still be subject to hostile fire.
CAVANAUGH: And I’ve also read that these new regulations, the new rules that the VA has, actually a relaxation of the rules that they have to seek disability benefits for PTSD, might actually benefit a lot of women soldiers, women veterans.
LANDIS: Well, of course, and that’s as it should be. You know, female veterans are prohibited by being in line units like, you know, platoons and companies that are actually in rifle assaults and providing those kinds of missions, however it doesn’t preclude them, you know, from being involved in what you would traditionally consider to be combat, hostile action.
CAVANAUGH: I’m speaking with Phil Landis. He’s president and CEO of Veterans' Village, San Diego. And my guest, Dr. Arnold Gass, is director of External Medical Services, Veterans' Healthcare System here in San Diego. And we’re taking your calls about the new rules for seeking disability benefits for PTSD. The number is 1-888-895-5727. Dr. Gass, if you could, I understand that you do the compensation and pension exams. What are they and what are they like?
DR. GASS: Actually, I don’t actually perform the exams but I oversee this activity. It’s something I’ve done on and off for the last 25 years or so. When a veteran’s claim is presented to us in the medical side of VA, we have to assess the claim. Basically, the claim process starts with the veteran contacting the Veterans Benefits Administration and presenting information or a history that he or she wants to be service connected or considers themself possibly service connected for a number of things, physical as well as psychological. My staff, which includes about 35 individuals, at the Mission Valley VA facility, is called the CNP Unit, the Compensation and Pension Unit. And our job is to turn around the exam within 28 days. We have 28 calendar days from the time the VA gives it to us, on average, that we have to turn this around. And so we set up appointments for patients who come in and see a psychiatrist or a psychologist. Up until now, we’ve had all psychiatrists doing this exam but we’ve added psychologists to our staff recently. The patient – the exam is called an initial PTSD exam. We allow at least an hour for that. Sometimes it takes a little longer. The patient is asked a number of questions about the stressor incident or, in the future, those things which might have been stressor equivalents and then asked a number of questions about how the patient is functioning, what may trigger these reactions like nightmares or something, and also a state of how they can function in general. We then – Our examiner then makes a diagnosis, patient has PTSD by the criteria, usually accepted from the Diagnostic and Statistical Manual IV, and then also indicates a level of functioning.
CAVANAUGH: I see.
DR. GASS: And then my staff turns this back to the Bureau of Veterans Affairs where the rating board actually makes the decision. So what I oversee are a staff of physicians, psychologists and others that do exams, and our job is sort of in the middle. We get it when the regional office, the BVA, sends us the request, we do our work and we make our diagnosis and our function statement, and we turn it back. And we do this fairly efficiently and that is the data that the rating board will use…
DR. GASS: …to adjudicate the claim.
CAVANAUGH: Now, it stands – it just stands to reason that most of the veterans that you see are from the Iraq and the Afghanistan war but do veterans come in after years of separation to see whether or not they can qualify for a disability based on PTSD from previous wars?
DR. GASS: Yes, they do. And, in fact, it’s not just PTSD. In the area of physical injury, because Gulf War I showed us like about a twofold increase in ALS, amyotrophic lateral sclerosis, which is known as Lou Gehrig’s disease, from the first Gulf War, any veteran still alive that had ALS can now come in and apply for benefits as if he came the day he first got the disease or she first got the disease. Traumatic brain injury is another thing that’s been extended retroactively. Now any person who was knocked out or lost consciousness, during his time or a time in the service, can apply for traumatic brain injury but the focus on that has been the OEF/OIF cohort.
CAVANAUGH: What does that mean?
DR. GASS: OEF?
DR. GASS: Yeah, that’s Operation Enduring Freedom…
CAVANAUGH: I see.
DR. GASS: …and Operation Iraqi Freedom. OEF is the Afghanistan war and OIF is the Iraq war.
CAVANAUGH: Got it.
DR. GASS: And so with – there’s a dwindling number of World War II and Korean War vets. Now our biggest number is actually Vietnam vets. But most – many of our new applicants are OEF/OIF veterans.
CAVANAUGH: Got it. Okay.
DR. GASS: So we do – we will do examinations on World War II veterans and Korean War veterans who have discovered that maybe what they’ve been suffering with or dealing with all their life could have arisen from their experiences in World War II or Korea.
CAVANAUGH: Very interesting. We’re taking your calls at 1-888-895-5727. Alan is on the line from North Park. Good morning, Alan, and welcome to These Days.
ALAN (Caller, North Park): Good morning and thank you very much for this program. I’m a volunteer with a local group, the San Diego Military Counseling Project. We’re a part of the nationwide GI Rights Hotline. And we can help people better understand the rules and regulations that govern their military service. We help out not only with things like PTSD but discharges or discrimination, gay, AWOL, UA, harassment, conscientious objection. So if people want to contact us, they can just go to Google or wherever they want to and find the GI Rights Hotline and our local group, the San Diego Military Counseling Project, we’d be glad to help people out on these issues.
CAVANAUGH: Okay, Alan, thank you for calling in.
ALAN: Thank you very much.
CAVANAUGH: Dr. Gass, what kind of medical care is a veteran entitled to?
DR. GASS: Well, that has changed over time. When – And I’m not an expert in this. Our Member Services section are more of an expert in this issue. But, traditionally, when a person received a medical – a military discharge, they had up to one year to come in for services. We call that prima facie and we take care of them.
DR. GASS: If a person is disabled, he or she will be given a percentage rating for disability and we are taking care of anybody who has a disability rating from zero percent all the way to 100%. At all times the veteran is eligible for care for those things which are service connected and, in general, for most things that aren’t because we’re a total service organization. We try to take care of the person not just the disease. Under legislation that I believe started under Bill Clinton, the term for eligibility for veterans to come in was first extended for two years then I believe was re-extended maybe for another two years, and now it’s five years.
CAVANAUGH: Now it’s five years.
DR. GASS: So combat veterans can come to us, facility, for all the medical care they need for the first five years after they’ve been discharged and if during that time or subsequently they apply for and are labeled service connected for various things, they will be able to get care for that as well as probably most of the rest of the medical care that they need.
CAVANAUGH: Let’s take another call. Mike is calling us all the way from Taos, New Mexico. I guess he’s listening on the web. Good morning, Mike. Welcome to These Days.
MIKE (Caller, Taos, New Mexico): Hi. Thanks for having this conversation. My question is this, are there monies available for PTSD solutions. And the other side of that question is what works? And specifically, I want to know if getting veterans back up into the hills, getting them exercising, archery or martial arts or any breathing or – what works?
CAVANAUGH: Thank you for the call, Mike. I appreciate it. Dr. Gass, Phil, I wonder if – I know that neither one of you say you are experts in PTSD but what might be the kinds of therapies that are being used to treat that now, Dr. Gass?
DR. GASS: The therapies that we have include individual therapy and group therapy. And most of the cases of PTSD from OEF/OIF, or Operation Enduring Freedom/Operation Iraqi Freedom, are individual. There’s something called Cognitive Behavioral Therapy, which goes under the acronym CBT, there’s supportive psychotherapy, that is talk therapy in which people just work with the things that they think they need to. Something called Seeking Strength, which helps to deal with – patients to deal with combination illnesses like alcohol and drug abuse as well as PTSD, and the therapy focuses on how the two could be linked. There are therapies at the Vets Center which is we have at least two of them in San Diego County that I’m aware of, one up in North County and one down near Balboa Park. There is prolonged exposure therapy, which I can’t define further…
DR. GASS: …and Cognitive Processing Therapy, which is CPT. It’s a 13-week group therapy that has many people recover by focusing on the stuck points, those things they’re stuck on related to past traumatic events that are continuing to cause problems and symptoms of PTSD. The group member, however, does not have to share exactly what the point was but let’s say it was a homosexual rape, not just combat, because PTSD can be convert – can be induced by other stressors, and the person doesn’t want to talk about that but he or she can’t get it out of their mind. Under something like Cognitive Processing Therapy over 13 weeks, there would be techniques, thought and homework given so that a person can try to work through those things.
CAVANAUGH: Phil, let me ask you, you deal with so many, many vets who are suffering from the effects of PTSD, do you hear about any kind of therapy that is cutting edge or really working?
LANDIS: Well, I think Dr. Gass, you know, made the point quite well that there is no magic bullet for any one individual, that we just don’t know, you know, what’s going to work best for any one particular person and so we try a lot of different things. And I think that was his point, and we do the same thing here at Veterans’ Village. There are a lot of very exciting, you know, cutting edge projects, a lot of it having to do with immersion therapy. You can take an individual, actually put them in a simulator, if you will, that simulates combat in Iraq and I haven’t seen this device myself but I know of it, and by measuring biometric barometers, you can provide a visual and you can couple that with sound and even smell while the person is going through these visualizations and help them work through them by exposing them to these kinds of events. This is something new and it has promise. Nothing – nothing really defines a hallmark magic bullet. You have to try everything.
CAVANAUGH: Let’s take another call. Christine is calling us from Carlsbad. Good morning, Christine, and welcome to These Days.
CHRISTINE (Caller, Carlsbad): Good morning. Such a great conversation today. I’m actually a therapist who works with our veterans with PTSD and I’m also a prolonged exposure therapist, so I can certainly tell you guys a little bit more about that. The first thing that I wanted to address was the – this relaxation of the rules…
CHRISTINE: …I think is wonderful. It’s been so difficult for the veterans, particularly because of their PTSD symptoms and, you know, the main symptom of the PTSD is avoidance and that’s avoidance of people, places, things but also about the thoughts and the memories. And to have to go in and to recount this story over and over again to somebody trying to prove that, yes, this event happened to me has been really difficult for these veterans. So I’m really excited to hear that some of these people that really do need the help will be able to get it more easily.
CAVANAUGH: What else has made it difficult for veterans to seek the disability benefits that they really sort of deserve from the Veterans Administration before these rules were relaxed?
CHRISTINE: Honestly, a lot of it’s just the paperwork and the bureaucracy. It’s getting into appointments that are delayed, you know. They can get one appointment for three months from now. The anxiety that they have about having to go in there and talk to a stranger. For a lot of them, they don’t like to drive. They don’t like to be in crowded office buildings, riding elevators. For the VA system, being in places where they’re reminded of the military, going in and seeing people with disabilities physically or people in uniform, all those things, I mean, can be triggers and really upsetting to the person which helps them to avoid more and say, well, I’m just not going to do it. It’s too hard, you know. And then they’re not getting the help that they need.
CAVANAUGH: Christine, thanks so much for calling in. You know, with what Christine has said, Phil, it comes – it may come as a surprise but it’s sort of the opposite side of this issue that I understand with these new relaxed rules there’s some concern about fraud, that people who were not in actual combat, might not really be suffering from PTSD, will apply for benefits and perhaps get them. What provisions for determining the merit of a claim are in place?
LANDIS: Well, I think fraud has always been with us in this process. Will the relaxation of the requirements expand this activity? Probably. Is that necessarily a reason not to do it? Of course not. More people will benefit as a result than not. And the process that we’ve been talking about for claims adjustment itself and for adjudication of claims weeds out the vast majority of these false claims. So I wouldn’t get stuck on, gosh, this is going to expand the number of false claims. Those’ll kind of take care of themselves as the process unfolds for their own adjudication. Some will slip through, that’s true, but the greater benefit will be that much more – many more – many more veterans will benefit as a result of it.
CAVANAUGH: Now, I know that the annual Stand Down for homeless veterans takes place in San Diego this weekend, Phil. How much of a factor is PTSD in homelessness?
LANDIS: Well, we think that there is a direct link to homelessness and trauma, whether the trauma is from a combat exposure, it could be from a sexual assault, it could be from just being on the street. Who knows? But trauma plays a major factor in homelessness, whether it’s a veteran homelessness or not, and we try and deal with that when it comes in the doorway. And speaking of Stand Down, this weekend – We had 928 participants last year, a record number. We are hopeful that we will not reach that number again.
LANDIS: We’re fearful that we will, that we will exceed it.
CAVANAUGH: Now, Dr. Gass, I understand that you started the medical tent at Stand Down years ago. Have you seen the medical needs of vets change over the years?
DR. GASS: Well, thank you for saying that. I’m the original medical director. This is our 23rd Stand Down. We – Our main – our function at Stand Down is to provide a medical facility for a community of up to 900 veterans and their sp – and their significant others and children as well as up to 2000 volunteers on a site for 56 hours. So that purpose has really never changed. As far as what veterans come in for, my – it has changed a little bit because the initial cohort of veterans was Vietnam veterans and back 25 years ago, on an average, they were probably around 45 years old. As they get older, they’ve got more chronic medical illnesses and psychological illnesses, discovered new things, became unemployed where they hadn’t been before. And so we not only provide acute and sub-acute medical care for Stand Down but we’re often picking up on chronic illnesses that we – veterans come in for. They had run out of their medicines, they haven’t gone to clinic for several years, and we try to stabilize them for the duration of Stand Down so they can take – they can get benefit from the services that are available there and then try to plug them in and get them associated with a number of healthcare facilities around town, including halfway houses, including going to the Vietnam Village of San Diego (sic), including being admitted to our hospital if they’re acutely ill or have psychological problems that require hospitalization. So things have changed. I think the aging of the population is one thing. And we’re also – we’ve also tried to expand our services each year so in the past we didn’t do much for HIV but over the last few years we screen for HIV, we test for tuberculosis and so forth and so on. So we’ve expanded our program and there’s been somewhat of a shift in the nature of the illnesses that we see.
CAVANAUGH: Phil, tell us the where and when about Stand Down.
LANDIS: Stand Down, the doors open Friday morning at 0600 and goes all day Friday, all day Saturday, with graduation late Sunday afternoon. And it’s held at the upper ballfield at the San Diego High School.
CAVANAUGH: Any changes to look at this year? Any new services?
LANDIS: We’re expanding some existing employment services, some of the medical services, we’re expanding the availability of prescription glasses this year over previous years, although it’s been one of our favorite tents. We’ve expanded – Actually we have acupuncture, if you will, and massage. It’s one of the favorite tents, comes as no great surprise.
LANDIS: Also our legal services, our homeless support, this year as last, we’re holding on Friday as opposed to Saturday.
CAVANAUGH: And in the very short time we have left, Dr. Gass?
DR. GASS: So to link the two topics together, in fact what has really pleased me over the years is that we’ve expanded our formal mental health capacity at Stand Down. We now have psychiatrists around the clock basically, 8 to 5 or 8 to 6 every day, and to noon on Sunday. One of our physicians, Steve Thorpe, is going to be doing a seminar session during the seminar sessions at Stand Down on PTSD. We will try to both treat people as well as invite them to join research studies if they’re interested. And so I think that one of the things that has changed is we’ve given them very strong focus to psychological care and follow through from that. Stand Down’s just the beginning, it’s not the end.
CAVANAUGH: Dr. Arnold Gass, thank you so much. I appreciate it. And Phil Landis, thank you.
LANDIS: You’re welcome, Maureen.
CAVANAUGH: If you would like to comment, please go online, KPBS.org/thesedays. Coming up, Constance tried to take her girlfriend to the prom. We’ll hear what happened next as These Days continues here on KPBS.