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2023 HSR&D/QUERI National Conference Abstract

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4071 — Compensation and Pension Exams for Military Sexual Trauma-Related PTSD: Examiner Experiences, Clinical Impacts on Veterans, and Best Practices

Lead/Presenter: Aliya Webermann,  COIN - West Haven
All Authors: Webermann AR (COIN – West Haven; Yale School of Medicine), ; Nester, MS (UNC-Greensboro); Black, AC (COIN – West Haven; Yale School of Medicine); Haskell, SG (Office of Women’s Health Services, Veterans Health Administration; Yale School of Medicine; COIN – West Haven); Rosen, MI (COIN – West Haven; Yale School of Medicine); Gianoli, MO (COIN – West Haven; Yale School of Medicine); Mattocks, KM (VA Central Western MA; UMass Medical School); Portnoy, GA (COIN – West Haven; Yale School of Medicine)

Objectives:
Over 12,000 claims for PTSD due to military sexual trauma (MST) are submitted annually to the Veterans Benefits Administration (VBA). Although the MST claims process has changed substantially since 2011, the core components remain intact: first, VBA reviews claims for a PTSD diagnosis and “markers” of MST (i.e., behavioral changes during or following MST), orders clinician-conducted compensation and pension (C+P) exams, and lastly, renders claims decisions that reflect perceived severity and functional impairment due to MST-related PTSD. VBA also is increasingly reliant on contract examiners, who conduct an estimated 80-90% of all C+P exams. In the context of these changes, little is known about the experiences and perceptions of VHA staff within the MST claims process, including C+P examiners. Prior work has demonstrated that the quality and outcome of PTSD C+P exams impacts veteran well-being and use of VHA mental healthcare, but no work has looked specifically at either staff or veteran experiences with the MST claims process. The current study aims to address these knowledge gaps through exploring the expectations, challenges, and decision-making processes of VHA clinicians who conduct C+P exams for MST, including perceptions of the clinical impacts of MST C+P exams on veterans (e.g., mental health symptoms, utilization of VHA mental healthcare).

Methods:
A total of 13 clinicians across four VA Medical Centers who conduct MST-related PTSD C+P exams were interviewed. Data were analyzed using rapid qualitative methods, which allowed for efficient and systematic data reduction and synthesis.

Results:
Themes that emerged from interviews included how examiners approach MST C+P exams, the potential impacts of MST C+P exams on veteran mental health and utilization of VHA mental healthcare, and examiner best practices. Examiners typically approached MST C+P exams assuming that they would be clinically and diagnostically complex, and some believed PTSD symptoms were easy to malinger. Examiners often used clinical interventions to provide care and support to veteran examinees. In terms of potential clinical impacts, examiners noted concerns about the harms of assessing MST markers given the potential of questioning the legitimacy of MST disclosures and indicating that MST needed to be “proved.” Further, examiners described unique considerations for groups who may underreport MST or face unique stigmas related to sexual victimization, including men and LGBTQ+ veterans. Lastly, examiners shared best practices for MST exams, such as pre-identifying markers before exams to avoid veterans having to repeat traumatic details, and concerns about potential retraumatization and the quality of exams by contracted examiners.

Implications:
Interviews with 13 VHA clinicians conducting MST C+P exams reflect common themes, and some discrepancies, regarding the clinical impacts of exams on veterans, and examiner efforts in conducting trauma-informed exams to minimize potential harms and retraumatization.

Impacts:
This project offers insight into a process entered by thousands of veterans annually with PTSD, and for some veterans, the C+P process may be their first entre into VHA services. Strengthening the C+P process by ensuring consistency and care for veteran examinees is a unique opportunity to enhance veteran trust in VHA care and willingness to utilize VHA mental healthcare.