I have a colleague working at a VA in New York who is tireless in his commitment to keeping many of us mental health workers at the VA nationally abreast of the latest in both print and electronic media on issues concerning modern combat veterans. Yesterday he sent me personally an FYI that I found quite thought-provoking: an entry by Dr. Elspeth Cameron Ritchie on TIME Magazine’s blog, Battleland, entitled, “The Unintended Consequences of the Current PTSD Diagnosis.” Her blog entry ends with the following question:
I do think that this is an incredibly important issue, which we, as a nation, need to discuss. As usual, I say that this is not just an Army or VA issue, but a national one. How do we want to compensate our vets, who have served in combat, whether or not they meet the technical definition of having PTSD?
I agree. So let me discuss her thoughts.
Before I do, though, a few preliminary “thoughts” of my own:
1. Let us consider a hypothetical soldier, Brandon, age twenty, a high school graduate, let’s say, from Danville, Indiana, a rural county seat that has, over the past twenty years, become a bedroom community for Indianapolis, about a half hour away.
2. Having grown up not too far from a large city, Brandon is somewhat sophisticated in the basic ways of the world, especially in how to get what he wants in the most direct manner he can. Therefore, to borrow liberally from a term so au courant among “those who know” in academe, i.e., social scientists, Brandon, albeit youthful, is nevertheless a “Rational Soldier.”
3. For purposes of this essay, the phrase “legitimately suffers the symptoms of the syndrome” is equivalent to saying that Brandon does so upon the oath of twenty high-powered psychiatrists who have examined him, i.e., ones who, having trained at Harvard/Yale/Columbia/UCLA, are therefore not simply mere members of the psychiatric hoi polloi (reminiscent of Judge Learned Hand’s “twenty bishops” so well-known to law students throughout the land).
4. For purposes of this essay, the phrase (or its equivalent) of “minimally suffers from the symptoms of PTSD” would refer to combat veterans who suffer from increased tension and maybe an occasional nightmare only on the last Sunday of May, on July 4, and on November 11 of each year (if any such veterans exist).
With that in mind, consider the following from Dr. Cameron Ritchie:
I am all for vets receiving the disability that is due them. But to give automatically 50% disability for one particular diagnosis creates a major incentive to get that diagnosis — and keep it.
So let’s consider Brandon in light of a “major incentive to get the diagnosis–and keep it.”
1. If Brandon legitimately suffers the symptoms of the syndrome, then the amount of disability is irrelevant to his “getting” the diagnosis.
In other words, he’s already got it.
2. If Brandon legitimately suffers the symptoms of the syndrome, then the amount of the disability might encourage him to seek compensation for what he legitimately has.
OK. Well, since that’s the purpose of the compensation system to begin with, no harm, no foul.
So how about:
3. If Brandon does get compensation for what he legitimately has, then he may not try to get better, lest he lose his steady paycheck.
From what I understand, social scientists consider this the moral hazard problem,
which, according to that fount of all knowledge, Wikipedia, means (as of November 28, 2012, that is) that Brandon, our Rational Soldier,
…will have a tendency . . .to be more willing to take a risk [e.g., not getting better by not participating adequately in treatment], knowing that the potential costs and/or burdens of taking such risk will be borne, in whole or in part, by others [i.e., taxpayers].
And even worse,
4. If Brandon does not legitimately suffer from the symptoms of the syndrome, then the amount of the disability payment might encourage him to claim that he suffers from the syndrome, even if he does not so suffer or only minimally so suffers.
Here the moral hazard is risk (i.e., getting caught in his deception) again being bankrolled by the taxpayer (either in wrongly-granted payments or the “transaction costs” of removing such payments from Brandon because of all those pesky due-process requirements inherent in government payments, brought to you by that infamous 1970 Supreme Court decision, Goldberg v. Kelly)
In these final two cases, Brandon has become either the Rational Freeloader or the Rational Fraud. The question, therefore, for all us taxpayers is: how many such Brandons are there in the modern military?
That, of course, is an empirical question, i.e., one that could actually have a numerical answer. From what I understand, however, to coin a phrase that seems to be de rigeur at the end of any peer-reviewed journal article, “further research will need to be done” to come up with that answer.
That, of course, is not to say that many people do not “know in their hearts” that there are more than a few such Bad-Brandons in the military–and now loose in America, smoking their cigarettes and drinking their Red Bulls with my hard-earned tax dollars–based, of course, on such people’s “clinical experience” or their “practical experience with real veterans” (sort of like how Karl Rove just “knew” that Megyn Kelly had to get those Fox number crunchers back in line with “reality” on Election Night, based, of course, on his years of practical, political experience).
The knowledge of my heart, of course, is no more, no less accurate. So, what the heck, given that, here’s what my heart says:
If Brandon was intense enough and motivated enough to sign up for the Army in a time of war, i.e., to sign up possibly to die at the age of twenty, then–call me a cockeyed optimist, if you must–Brandon very possibly is so intense and so motivated, the last thing he is going to want to do is face himself in the mirror every day and say “Another Camel, another Red Bull today! What’s a few nights of blood-soaked, screaming Iraqi kids running after me in my dreams, screaming ‘Killer! Killer!’, when I can watch all the ESPN I want!”
Have no fear, though: plenty of VA employees seem to believe it to be their patriotic duty to monitor the sanctity of the coffers of the United States Treasury and ferret out any and all wily Brandons who might sneak past either the lazy eyes of some reviewing bureaucrat or the softie, do-gooder-liberal eyes of some Dr.-Deaton-type. Justice will prevail!
OK, enough. Dr. Cameron Ritchie also writes:
In my experience, there are two types of Soldiers: those though will not go near mental health because of worry about their career, and those who are already getting out, who are encouraged by the system to stay to get that PTSD diagnosis.
I have to be honest: I’m not quite sure what this means. I do understand the “not go near mental health” part. It’s the latter part. So let me try this:
1. Suppose Brandon is planning on getting out of the Army, and Brandon is a Rational Soldier.
2. Situation One: “The System” encourages Brandon to acknowledge what is true–that he legitimately suffers from the symptoms of the syndrome–and to stay in the military long enough so that he will be recognized for his sufferings and be compensated for them so that he will not have to work in the civilian world afterwards.
It strikes me that it’s a bit sketch to argue the contrary to this, although I’m sure that there are people who would, with a sincere heart, be more than willing to do so. However, at this point, I’m going to mark this one as another example of “no harm, no foul.”
3. Situation Two: “The System” encourages Brandon to stay in the Army long enough so that he can have the experiences necessary to cause him legitimately to have the symptoms of the underlying syndrome so that he will not have to work in the civilian world afterwards.
Well, I guess one could argue that too, but, my, doesn’t that take us into interesting territory? It would seem to give a meaning to “The Rational Soldier” heretofore unprecedented. I mean, would that be quite the reason, or what?
4. Situation Three: “The System” encourages Brandon to stay in long enough so that he can have the experiences necessary to claim that he suffers from the symptoms of the syndrome, even if he does not or does so only minimally, so that he will not have to work in the civilian world afterwards.
Now we’re back to Brandon the Rational Fraud. See the above.
OK, next:
Some argue that this automatic disability is not helpful. It creates an incentive for all military members to get the diagnosis of PTSD, rather than depression or anxiety.
Let us consider Brandon, PTSD, and Depression.
1. Again, suppose Brandon is a Rational Soldier.
2. If Brandon legitimately suffers from the symptoms of both syndromes, i.e., PTSD and depression, he will therefore have an incentive to prefer to receive the official designation of PTSD because he will get paid more for it.
OK, well, at least in the VA system, Brandon could receive compensation for both PTSD and depression. I’m not really sure, therefore, that Brandon is going to have to face the combat veteran’s equivalent of a Sophie’s Choice, as if he were going to have to stand at the doorway of the local Veterans Benefit Administration office and instead of screaming “Take the girl!”, scream “Take the depression!” (And, yes, I’m aware of the irony of bringing up Styron in this context). I could be wrong, though.
2. If Brandon does not legitimately suffer (or only minimally suffers) from the symptoms of PTSD (whether he does or does not from those of Depression), then he has an incentive to claim that he has PTSD and then perhaps not acknowledge his true depression, i.e., he is being rewarded both for lying and for not facing facts.
Now we have both Brandon the Rational Fraud and Brandon the Rational Dodger. I think that this is another empirical question, so I’ll leave you to your heart again to decide how much we should be worrying about this possibility.
But now, remember: we’re talking depression here, not just sadness, i.e., we’re talking about a physical illness that causes profound physical and psychological changes. Therefore, in #2 just above, we’d be considering a case in which combat did not trigger significant PTSD symptoms but did trigger Major Depression. I have to say, having practiced psychiatry for thirty years now, I’m having a hard time imagining that scenario. But all things are possible, I guess. So if this is where Brandon ends up, then are not these his two dilemmas?
1. If Brandon had a predisposition toward a major psychiatric disorder (here, depression) and combat experiences stressed him to the point of expressing the symptoms of that disorder without PTSD–then, well, is it fair for him to receive PTSD-level compensation when, after all, all that Brandon really has is just depression?
2. If Brandon had a predisposition toward a major psychiatric disorder (here, depression) and military life itself stressed him to the point of expressing the symptoms of that disorder without having had combat experiences–then are we not asking why should Brandon the Combat Veteran Depressive get all the attention/money when Brandon the Extended-Time-Away-From-Family-Yet-Without-Combat Depressive doesn’t?
Well, now, those are interesting questions.
Consider then the following from Ms. Cameron Ritchie:
I repeat: the issue for me, and many of my colleagues, is not whether the veterans deserve disability after an unrelenting 11 years of war. It is whether one diagnosis – PTSD — deserves more than schizophrenia, or bipolar disorder or depression.
PTSD now receives an automatic 50% disability rating from the Army, no matter how mild or severe the symptoms are.
What I am trying to get at is the issue of automatically giving a single diagnosis a particular rating. And not giving the same for all the other psychological reactions to war, including grief and depression.
By personifying PTSD, she asks: is PTSD getting more of the share of the attentional/monetary pie than its “siblings” in the Diagnostic and Statistical Manual of Psychiatric Disorders, Fourth Edition, Text Revision (DSM-IV-TR), the “Bible” of psychiatric diagnosis? Has PTSD unfairly become the favored child?
After, all, what about grief and sadness, eh? What do we say to Brandon, as a society?
Consider two possible choices:
1. “Look, Brandon: you signed up for this. Did you really think that you could go to war and not come back with some grief and sadness? You’ve got to take the bad with the good in life, Brandon. We paid you combat pay in while you were in the theater, and we’re now paying you with “Thank you for your service” handshakes in airport terminals, opportunities to stand up and be applauded before the band plays “Stars and Stripes Forever” at the Fourth of July concert, a free college education, and a lifetime access to the biggest single-payor healthcare system in the United States. Don’t look a gift horse in the mouth, Brandon. Buck up, boy.”
2. “Look, Brandon: you promised us that you would protect us, the United States, whenever asked by those in authority above you to do so. We elected George Bush, Barack Obama, the Congress of the United States, the ultimate bosses of those above you. We knew those politicians asked you to go to Iraq and Afghanistan to protect us, whether or not we believed then or believe now that was ever the reason. We weren’t willing to give up our lattes and our bran muffins to cause enough political turmoil to have George, Barry, Nancy, John, Harry, Mitch and Company actually think twice about asking you to die for us. We let you give up your youth so that most of our children did not have to give up theirs. We asked you to hold your best friend from high school–remember that, high school, what, about three years ago, maybe?–as he screamed for his mother one last time, as you contemplated facing that very woman one day with that final image of him in your mind, that voice ringing in your ears. We asked you to decide now–right NOW, damn it!–whether to shoot those two Iraqi dudes driving toward you who a). might be bad guys, or b). might have turned down the wrong road and therefore are now terrified beyond mere human comprehension. We asked you to wonder whether this next run of chow to the next base, the next run of water, of Burger King patties might be your last trip “on the road,” with no crazy Kerouac ending to it, just possibly death, man, dead death. We asked you to grieve, to cry, to rage, to shake, to be up night after night after night, whether or not with nightmares, wondering “what if, what if . . .” so that most of our kids wouldn’t have to do the same. Thank you for your service, Brandon.”
How do we want to compensate our vets, who have served in combat, whether or not they meet the technical definition of having PTSD? Dr. Cameron Ritchie asks us.
How do we, indeed, Elspeth. How do we, indeed.
Image may be NSFW.
Clik here to view.
Image may be NSFW.Clik here to view.
