In most instances, it is not realistic, nor is it typically the standard of care, to expect a therapist to be an investigator to validate the historical truth of what a patient discusses in therapy…. In contrast, the role of a forensic examiner is, among other things, to offer opinions regarding historical truth and the validity of the psychological aspects of … claims. The accuracy of this assessment is almost always more critical in a forensic context than it is in psychotherapy (p. 53).

[T]he psychotherapeutic process is rarely adversarial…. Forensic evaluation, although not necessarily unfriendly or hostile, is nonetheless adversarial in that the forensic evaluator seeks information that both supports and refutes the [claimant’s] assertions (p. 54).

Therapy is intended to aid the person being treated…. Forensic examiners strive to gather and present objective information that may ultimately aid a trier of fact … to reach a just solution … (p. 54).

The VASRD process introduces additional complicating factors. Examination parameters are set by raters who are required to tailor claims to meet VASRD criteria and requirements. However, these may not represent the current state of the medical science6 and may thus compel clinicians to use tools or techniques that they consider to be substandard. Further, C&P examinations may be conducted by clinicians who have a prior or future therapeutic relationship with the claimant. In a 2004 VA instructional video on the PTSD C&P process, a senior VA medical officer indicated that this created a potential conflict of interest and might lead veterans to be less than forthcoming with clinicians providing care to them (VA ESS, 2004).


VA identified several issues related to the conduct of C&P exams that were of particular interest: the use of the GAF in examinations, the separation of symptoms among PTSD and comorbid disorders, the time between the stressor and the appearance of symptoms related to it, and the value of standardized testing in the conduct of examinations. These are addressed below.

Use of the GAF in Compensation and Pension Examinations

The charge to the committee indicated that the role of the GAF score in evaluating PTSD was an area of great interest (Szybala, 2006). It noted that some advocates have argued for an increased dependence on the GAF score


One example of this—the use of the GAF in C&P examinations—is discussed later in this chapter.

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