tions. If clinicians do not evaluate for negative race-related events that may have led to psychiatric problems, the ethnic minority veteran may not be receiving the appropriate disability rating or compensation. Thus, it behooves VA clinicians to be particularly attentive to examining possible race, ethnic, or cultural issues among ethnic minority veterans.

Summary

The committee’s literature review indicates that there are many barriers to recovery for Vietnam veterans diagnosed with PTSD. Some of these are common to all people with disabilities, some are experienced by all those with mental disabilities, and a few are unique to veterans, to those with PTSD, and to persons using the VA disability system.

The literature suggests that many barriers are endemic to the programs used to provide services to those with disabilities, while some are unfortunate consequences of the symptomatology of certain disabilities, and others result from entrenched attitudes about the disabled and, in particular, about those with psychiatric illnesses. There are no easy solutions: experience with civilian benefits systems has shown that the problems will be difficult to remedy.

THE EFFECT OF COMPENSATION ON RECOVERY

One of the key issues that the committee was asked to assess is how PTSD compensation might influence veteran beneficiaries’ attitudes and behavior in ways that could serve as barriers to recovery. The committee was specifically asked to evaluate the evidentiary basis for various influences of compensation on treatment and recovery (Szybala, 2006).

The effect of disability compensation on beneficiaries’ behavior has long been an issue in research and in practice, both in the general population (IOM, 1991; Bellamy, 1997) and for the military and veterans (IOM, 1999; Drew et al., 2001; Mossman, 1996). Attention has increasingly shifted to the more subjective ailments and injuries, such as chronic pain (Sullivan and Loeser, 1992; Rohling et al., 1995) and mental disorders (Estroff et al., 1997), particularly PTSD (Rosen, 2004, 2006; Mossman, 1994; Guriel and Fremouw, 2003). Because a positive finding often results in monetary or other types of compensation, assessing psychopathology within the context of disability is almost always complicated by the possible influences of secondary gain. Indeed, secondary gain has long been hypothesized to increase the possibility that symptoms and their effects will be exaggerated, both during the course of treatment and during recovery, and both for general disabilities and for combat-related PTSD in particular (Atkinson et al., 1982; APA, 1994; Resnick, 1997). In recent years, however, because of the



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