- Email: [email protected]
The effects of compensation on psychiatric disability
Sot.
Sci. j\Icv/.
Prmed
Vol. 17. No. 7. pp. 439--44X
in Great
Bnrarn.
THE
All
rights
0277-‘)536’X3!0704~Y-O5~)~.(~)~0
1983
Copyright
reserved
EFFECTS
OF COMPENSATION DISABILITY
0
19X.3Perg;imon Press Lid
ON PSYCHIATRIC
JOSEPH L. PERL and MARVIN W. KAHN Department
of
Psychology.
University
of Arizona,
Tucson.
AZ 85721.
U.S.A.
r0r Abstract-Psychiatrically impaired veterans who were receiving 1005;. partial or no compensation their psychiatiic disabilities were compared on type and level of psychopathology, self-esteem. locus of control and treatment utilization. All groups were highfy elevated on measures of psychopathology. There were no differences between groups on psychopathology measures, except that the loo:‘,;, group scored significantly higher than the uncompensated group on hostility. Differences in locus of control were not found. On 3 of IO subscales. partially compensated patients reported higher levels of self-esteem than patients in one or both of the other groups. Uncompensated patients required the most hospitalization. Those who were receiving 1000, disability compensation required less hospitalization and the number of days they spent in the hospital was significantly reduced following attainment of full compen-
sation
Disability payments to emotionally disabled individuals through governmental sources such as Social Security and Veterans Administration compensation amount to vast sums of money. In 1978 the VA paid a total of S5.077.000,000 in disability compensation to 2,258.OOO physically and psychiatrically impaired individuals whose disabilities were incurred or aggravated while they were in the service [I]. While the intent of this policy is humane. it has been criticized for creating so much secondary gain that the recipients may resist therapy and rehabilitation, resulting in prolonged or permanent disability. There is a surprising scarcity of research literature on this topic. There have been no systematic research studies investigating the effects of the Veterans Administration compensation system on the personality and behavior of compensated veterans. Much of the literature existing concerning compensation focuses on physical rather than psychiatric disability. In a review article. Carnes [2] concluded that the evidence suggests that individuals with “hypochondriacally organized personalities” were nearly always rehabilitation failures. In a well controlled study with 56 chronic psychotic patients. Griffiths [3] showed that low self-confidence. lack of drive and an attitude that the disability was serious were predictive of poor response to rehabilitative efforts. Similar findings are reported by Campbell er nl. [4]. In a study of post-hospitalization adjustment of schizophrenics. Lorei and Gurel [S] found that employment histor!. was the best predictor of postdischarg,e employment and that number of previous hospitahzations was the best prognosticator of readmission. Walker and McCourt [6] found no association between work in the hospital and subsequent employment outside of the hospital. Ruesch and Brodsk\- [7] focused on the concept of social disabilit>. The! state that impairment is a function of the person. but disability is a function of the social Requests for reprints should be addressed to: Marvin W. K;ahn. Department of Ps!cholo_g~. University of Arizona. Tucson. AZ 85’21. U.S.A. \‘\I
I- -
,
439
situation. Ruesch [83 emphasized that the primary goal of psychiatric hospitalization is social rehabilitation, not undoing psychopathology. More recently Weinstein [9] has detailed stages of what he calls the “disability process”. He concludes that persons who become enmeshed in .this process are typically highly dependent. When difficult circumstances arise or support is withdrawn, they tend to experience a precipitous drop in productivity and self-esteem. Then explanatory events such as injury or illness occur and are used as a rationalization for the decline in competence. Treatment fails and the disability stabilizes, leading to increased dependency and decreased tension. Job productivity drops off entirely but self-esteem returns to a higher level as an ‘honorable disability’ becomes firmly entrenched. Weinstein’s model appears to fit a number of other studies including those of Hirschfield and Behan [IO]. Brodsky [l l] and Martin [12]. In general these studies suggest that people who become involved in a compensation system may resist attempts at rehabilitation. Typically they are passive, dependent, unmotivated, guilty, anxious individuals who are prone to depression. They tend to be poorly educated, unmarried people with backgrounds replete with unstable family relationships, poverty, alcohol abuse, job failure and multiple social problems. Further, they tend to avoid dealing with internal problems, focus blame for their difficulties on external forces and resist cure tenaciously, treating helping professionals with hostility and seeking out people who believe they are permanently disabled. One aspect of the present study was to investigate the applicability of Weinstein’s concept of the disability process to psychiatrically impaired veterans. While a psychiatric disability may not be considered as honorable as a physical disability. it does potentially provide considerable secondary gain. Chronically psychotic individuals typically are treated gingerly and taken care of by family members who fear provoking additional psychotic breaks. However. psychiatrically impaired veterans are sometimes forced to work hard fo secure and main-
440
JOSEPH
L.
PERL
and
tain disability benefits. They must prove the severity of their impairment with frequent hospitalizations, visits to outpatient therapists. unemployment and yearly rating exams. Once declared disabled some continue to struggle to achieve ‘permanently and totally disabled’ status and collect 1007; service-connected disability payments (as of January 1979. $810 per month tax free). The process of seeking full compensation can last many years. Other sources of income. most notably Social Security disability payments, are available to supplement the VA compensation. Two studies have looked at service connection as a variable in compensation research. Walker and McCourt [6] found no association between service connection and post-discharge employment but Lorei and Gurel [S] found that veterans receiving the largest compensation checks were least likely to find jobs after hospital discharge. Thus far, however. there has been no study which has systematically compared groups receiving different amounts of compensation. The purpose of the present study was to examine the impact of the VA compensation system on selected aspects of the personality and behavior of psychiatrically disabled veterans. Psychiatric patients receiving full, partial and no disability compensation were investigated. Among the questions addressed in the study were: (1) What is the relationship of the degree of psychopathology of a given individual to the amount of compensation and level of disability rating? (2) How is a patient’s level of self-esteem related to the level of compensation they receive? (3) What is the association between level of compensation and ‘the patient’s utilization of outpatient and inpatient treatment facilities?
MARVI\
W.
KAHS
l(NO, yroup. This group was composed of 26 individuals. each of whom had been receiving IUO”,, service-connected compensation payments for at least the last 5 years. 1ww,> group. This group was comprised of 31 psychiatrically disabled subjects. each of whom had been receiving between IO”,, and 90”,, serGce-connetted compensation payments for a minimum of the past 5 years. Fluctuation in disability rating was permissible in this group as long as the amount of disability remained within the l&90”. range. Uncornpertsated yroup. This group was composed of 24 psychiatrically impaired patients who. over the last five years, received no compensation for their disabilities from the Veterans Administration. Procedures Each subject was administered an assessment battery which consisted of the Rotter Locus of Control Scale [ 131, the Tennessee Self Concept Scale [ 141. the Symptom Checklist-90-Revised (SCL-90-R) [ 151 the Minnesota Multiphasic Personality Inventory [ 161 and a 72 item demographic questionnaire developed for this study. The demographic questionnaire included items about marital and employment status. educational background. attitudes toward the respondent’s treatment and other topics. In addition. a search of each patient’s medical records was carried out to obtain indices of the patient’s help-seeking behavior including hospital utilization and number of outpatient psychotherapy visits. For the most part, one-way analysis of variance procedures were employed to compare the three groups on the assessment measures. When such analyses revealed that a significant difference existed, a Scheffe post-hoc contrast test was conducted to determine the source of the difference.
METHOD
RESULTS
Subjects
Participatiorl
Subjects were recruited from among psychiatric outpatients seen at a mental hygiene clinic of a Veterans Administration Medical Center. All were male veterans between the ages of 26 and 72, who had a psychiatric diagnosis (either neurosis or psychosis) documented in their hospital records. Of 154 veterans who were approached, 71 agreed to participate. The subjects were classified according to amount of compensation, lOOS/,, l&90% and uncompensated. There were two overriding reasons that veterans receiving 10-90’4 compensation were grouped together, despite what appears to be a wide range of disability payments, and those receiving 100% payments were placed in a separate group. The difference in monetary benefits between 10% status ($44 as of I January 1979) and the 90% category ($450) is only slightly larger than the relatively dramatic leap from 90% ($450) to 100% ($809) compensation status. In addition, there may well be an equally imposing psychological gap between 90 and 100% disability as loom/, disabled veterans, unlike their status, counterparts in the l(r90°/0 range, are declared ‘totally disabled’ or ‘totally and permanently disabled and are assumed to be incapable of maintaining employment. The composition of each group follows,
Somewhat under 50% of those who were approached regarding participation in the study volunteered to do so. The level of compensation being received was related to willingness to participate. Those receiving compensation tended to be less likely to volunteer than those who were not, though this comparison approached significance only CZ’ (I) = 2.84, P < 0.11. Forty percent of those with 100% disability volunteered, 43.8% with partial disability volunteered, while 51.5% of the uncompensated veterans did so. Demogruphic Jactors The three groups were not significantly different in age (mean age was 50.2 years). religion. education. marital history or alcohol-drug abuse history. Furthermore, the proportion of patients diagnosed psychotic vs neurotic in each of the three groups was not significantly different. Chi square tests revealed that subjects in the fully compensated group were significantly more likely to have been unemployed throughout the past 5 years than members of the other groups [x’ (4) = 13.95. P < O.Ol], whereas partially compensated group members were significantly most likely to have held a job throughout the past 5
The effects of compensation
on psychiatric disability
441
Table I. Significant analyses of variance for personality questionnaire scales Variable
Source
d.f.
SS
Between groups Within groups
2 68
781.54 6235.64
Total
70
7017.18
Between groups Within groups
2 68
8484.55 92.874.04
Total
70
101.358.59
Moral-Ethical Self Concept (Tennessee Self Concept)
Between groups Within groups
2 68
869~47 5392.73
Total
70
6262.20
Family Self Concept (Tennessee Self Concept)
Between groups Within groups
2 68
I 136.42 5990.23
Total
70
7 126.65
Hostility (SCL-90-R)
Total Self Concept (Tennessee Self Concept)
MS
F
390.77 4.26* 91.77
4242.27 3.1 I * 1365.79
434.73 79.30
5.48t
568.20 88.09
6.45t
*P < 0.05; tP < 0.001. years. The fully compensated veterans were significantly more likely to have done volunteer work outside the VA than were the other two groups [x2 (2) = 10.91. P < 0.011. Psychopotholog~ aud compensation The MMPI mean profiles for all three groups were indicative of very severe psychopathology. For all three groups there were gross elevations, with group means peaking on the schizophrenia and depression scales. However, there were no significant differences among the groups on any of the three validity or ten clinical scales and profile patterns were almost identical for all three groups. On the SCL-90-R the three groups again had very similar profile patterns which were elevated and very similar to the normative profile for this test for psychiatric outpatients. There was one significant difference among the groups on the ten SCL-90-R subscales. that being on the hostility subscale. The 100% compensation group scored significantly higher on hostility than the uncompensated group as indicated in Table 1.
All three groups indicated very poor self concepts as compared to normative data for the Tennessee Self Concept Scale [ 14). This was true for all subscales. There were. however. significant differences on three self-esteem subscales; total self concept, moral-ethical self concept and family self concept. Subjects in the partially compensated group reported possessing significantly more positive self concepts than IOOY, compensation group members on all three of these subscales and than subjects in the uncompensated group on the moral-ethical subscale.
As a whole. the subject sample generated a mean score (9.61) that was somewhat external when compared with normative data [ 131. Contrary to expectation. self-perceived locus of control was not related to
the amount of compensation being received. The group means were as follows (the higher the score, the more external): 100% group, 10.92 (SD = 5.23); IO-90% group, 8.14 (SD = 4.60); uncompensated group 9.42 (SD = 3.72). Compensation and treatment variables Compensation level and treatment. A comparison of the number of psychiatric outpatient therapy visits made during the past 5 years indicated no differences in outpatient utilization as a function of compensation level. The means for all three groups were approx. 25 visits. However, with regard to hospitalization during the past 5 years, there were significant differences. Because of extreme scores and the resultant large standard deviations (larger than the means), the Kruskal-Wallis one-way analysis of variance, a non-parametric test, was used to analyze three related hospitalization variables: number of hospitalizations in the past 5 years, number of 21 day hospitalizations in the past 5 years (veterans who are lO-90% service-connected are entitled to temporary 100’4 compensation payments for the time they are hospitalized if their stay in the hospital exceeds 21 days), and the total number of days spent in the hospital during the last 5 years. The latter analysis (total hospital days), corrected for ties, produced a statistically significant difference (x2 = 8.34, P < 0.05). The mean ranks were 44.9 for the uncompensated group (mean = 56.79 days, SD = 92.51), 31.5 for the 100% group (mean = 18.04 days, SD = 39.37), and 31.5 for the l&90% group (mean = 23.57 days, SD = 55.88). Thus, subjects in the uncompensated group spent significantly more days in the hospital than subjects in either of the other two groups. The IO-90% group and the 100% group did not differ from each other on this dimension. The same pattern of results held true for number of hospitalizations in the last 5 years (x2 = 7.02, P c 0.05).
442
JOSEPH L. PERL and MARVIS W. KAH\
In sum. it was demonstrated that, in the past 5 years, subjects in the uncompensated group were hospitalized significantly more times and for longer periods of time than were the subjects in either of the two compensated groups. Compensated increase and treatment usage. When compensation increases were to other than a loo”/, rating, there were no differences in either the number of outpatient therapy visits or days spent in the hospital in the years before and after increases. Nor were there any differences in the number of outpatient therapy visits made in the year before and the year after veterans in the 100% group obtained their loo”/; disability rating. However, a matched sample t-test for 22 subjects contrasting the number of days spent in the hospital in the year before members of the 100’4 group obtained a 100’~ disability rating with the number of days spent in the hospital in the year after this change revealed a significant difference (t = 2.75, d.f. = 21, two-tailed P < 0.01). Members of the 100% group spent significantly more days in the hospital in the year prior to obtaining their 100% disability rating (mean = 108.82 days, SD = 101.71) than in the year after attaining a 100’4 rating (mean = 37.73 days, SD = 59.63). Another matched sample t-test was used to compare days spent in the hospital in the years before and after the 100% rating was declared permanent (no longer subject to reduction). Even though data from only 9 subjects were available for this analysis, a significant difference emerged (t = 2.45. d.f. = 8, P < 0.05). Significantly more days were spent in the hospital in the year before the 100% rating was made permanent (mean = 109.89, SD = 135.94) than in the year after (mean = 9.22. SD = 21.22). DISCUSSION
In terms of the focal questions addressed by this study, the findings were surprising. There was no significant association between degree of psychological distress or psychopathology and level of compensation. The degree of psychopathology was extreme, but not different, for all groups regardless of whether or not they received compensation, and regardless of the level of compensation. Thus, compensation for psychiatric disability, in this situation at least, would seem to be based on factors other than degree of psychopathology. Degree of psychopathology may be a necessary but not sufficient basis for establishing disability levels, or it could be that the judgement process is arbitrary and very unreliable, or even that psychopathology is not the crucial factor in the judgement. But if psychiatric disability rating is not based on degree of psychopathology, what is the basis and should this not be made explicit? The only factor of psychopathology that did differentiate among the groups was the hostility scale of the SCL-90-R. Hostility was significantly greater for the 100% compensation group than for the uncompensated group. This would be consistent with a hypothesis that the ability to express hostility may be a crucial factor in obtaing full psychiatric disability compensation. (Perhaps the VA compensation system provides the ‘squeaky wheel’ with the largest dis-
ability checks.) If this hypothesis Lvere true. it could help explain the lack of association between degree ot psychopathology and level of compensation. Alternatively. the dependency that results from almost total reliance on government funds to ensure financial security might engender hostility in the recipients of 1009; disability benefits. However. since the hostility variable was the only one of many comparisons to reach statistical significance. it may reflect only a chance difference. In attempting to understand the overall lack of association between degree of psychopathology and level of compensation. it should be noted that the measures used here were self report measures. Perhaps other or more sensitive measures would show the more expected differences among the groups, These measures are. however. widely used and validated. The second question addressed by the study concerned the relationship between a patient’s level of self-esteem and the level of compensation which the patient receives. Based on Weinstein’s model. it was hypothesized that those receiving 100°, disability compensation would demonstrate the highest level of self-esteem since their disabilities, initially associated with decreased self-esteem, had been socially sanctioned and achieved the status of ‘honorable disabilities’. Results were contrary to expectation. Whereas all groups indicated very poor self regard. the partially compensated group was higher than one or both of the other groups on three of the ten selfesteem subscales. A possible posr-hoc explanation hinges on the fact that partially compensated veterans have not been declared totally disabled and unemployable. but have been given confirmation of impairment. Thus. productivity should not jeorpardize the disability rating and is apt to be valued by the veterans and significant others as it persists despite decreased expections. Enhanced self-esteem is a likely offshoot of continued productivity in spite of a validated disability. The data showing that partially compensated veterans were significantly more likely to have held a job throughout the past five years than subjects in the other groups lends further credence to this explanation. The relatively low self-esteem reported by loo”, group members may reflect the fact that psychiatric disabilities are poorly understood in this society and not viewed as ‘honorable disabilities’ in the same way as are physical injuries incurred in the service. Thus, total psychiatric disability may lead to social rejection rather than social sanction and to increased defensiveness instead of enhanced self-esteem. On the other end of the continuum. uncompensated group members’ unsuccessful pursuit of validation of their disabled status may engender a poor self concept. In terms of the third and last question raised by this study, the findings concerning the relationship between the amount of hospitalization and compensation status are of considerable note. Conventional logic would suggest that those who have been judged loo”,” disabled would require the most hospitalization, while those who have not been given a disability rating would require the least. The data show just the opposite. Those without compensation were hospitalized significantly more often and for longer
The effects of compensation periods than were those with compensation. Utilizing Weinstein’s ‘disability process’ schema, uncompensated veterans. despite their documented diagnoses. mav be locked in an ongoing struggle to demonstrate the extent of their impairment and to achieve ‘honorably disabled’ status. It would follow that a way to reduce hospitalization for psychiatric disability under the present system is to grant compensation for the disability. However. results of the present study also indicate that a lOO:, disability rating based on a psychiatric disorder is associated with diminished selfesteem. This may be particularly true in a nation in which the work ethic is highly valued and psychological distress is not well accepted or understood. For those veterans receiving compensation, increases in disability status to other than a 100% rating were not associated with any changes in inpatient or outpatient hospital utilization rates. However, the attainment of a lOOo/0disability rating was related to a significant decrease in the amount of time spent in the hospital during the following year. This striking finding highlights the potent impact of the VA compensation system and speaks to the financial and psychological meaning of a 100% rating. The achievement of ‘total disability’ status and especially ‘total and permanent disability’ status may engender a reduced sense of financial and emotional stress and/or a lowered need to demonstrate the extent of the disability. The latter conclusion is supported by the fact that the rating boards which make decisions on compensation status almost always consider the number of days veterans spent in the hospital, but rarely have access to data on outpatient visits (a variable which appeared impervious to change in this study). As long as there is a compensation system for emotional disability, the present results suggest that, from an economic point of view, granting disability compensation may be less expensive than the cost of the high rate of hospitalization which occurs without it. However, the self-esteem data should serve as a warning that deleterious psychological consequences may result from attainment of total disability status. Further research is needed to look more closely at the economic and phychological costs and benefits of the VA compensation s_ystem. As disability compensation
on psychiatric disability
443
programs continue to flourish, they must be scrutinized to ascertain the bases for ratings decisions and to determine whether such programs arc actually enhancing or impeding rehabilitative efforts. REFERENCES
Office of Controller, Reports and Statistics Service. Trend Dutcr 1954-197X. 1979. to failure. 2. Carnes G. D. Identifying clients predisposed J. Counsel. Psvchol. 20. 79-83. 1973. of chronic psychotic .7 Griffiths R. f>. Rehabilitation patients. An assessment of their psychological handicap, an evaluation of the effectiveness of rehabilitation, and observations of the factors which predict outcome. Psychol. Med. 4, 3 16325, 1974. 4. Campbell H. G., Clarkson Q. D. and Sinsabaugh L. L.
MMPI identification of nonrehabilitants among disabled veterans. J. Pew. Assess. 41, 266-269. 1977. Lorei T. W. and Gurel L. Demographic characteristics as predictors of posthospital employment and readmission. J. consult. clin. Psychol. 40, 427-430. 1973. J. Employment experience 6. Walker R. and McCourt among 200 schizophrenic patients in hospital and after discharge. Am. J. Psych& 122, 3 16-3 19, 1965. 7. Ruesch J. and Brodsky C. M. The concept of social disability. Arch. gen. Psychiat. 19, 394-403, 1968. and social disability. J. nera. 8. Ruesch J. Hospitalization menf. Dis. 142. 203-214, 1966. 9. Weinstein M. R. The concept of the disability process. Psychosomatics 19, 94-97, 1978. 10. Hirschfeld A. H. and Behan R. C. The accident process: I. Etiological consideration of industrial injuries. J. Am. med. Ass. 186. 193-199, 1963. 11 Brodsky C. M. Social psychiatric consequences of job incompetence. Comprehen. Psych& 12. 526536. 197 1, 12. Martin R. D. Secondary gain, everybody’s rationalization. J. occup. Med. 16, 800-801, 1974. 13. Rotter J. B. Generalized expectancies for internal versus external control of reinforcement. Psycho/. Monogr. Germ. App/. 80, l-28, 1966. 14. Fitts W. H. Tennessee Self Concept Manual. Counselor Recordings and Tests. Nashville. TN. 1965. 15. Drogatisi. R. SCL-Y&Revised Manuul I. Johns Hopkins University School of Medicine. Baltimore. MD, 1977. 16. Hathway S. R. and McKinley J. C. A multiphasic personality schedule: I. Const&ction of the schedule. J.
Ps~choL~lO. 249-254. 1940.
Sci. j\Icv/.
Prmed
Vol. 17. No. 7. pp. 439--44X
in Great
Bnrarn.
THE
All
rights
0277-‘)536’X3!0704~Y-O5~)~.(~)~0
1983
Copyright
reserved
EFFECTS
OF COMPENSATION DISABILITY
0
19X.3Perg;imon Press Lid
ON PSYCHIATRIC
JOSEPH L. PERL and MARVIN W. KAHN Department
of
Psychology.
University
of Arizona,
Tucson.
AZ 85721.
U.S.A.
r0r Abstract-Psychiatrically impaired veterans who were receiving 1005;. partial or no compensation their psychiatiic disabilities were compared on type and level of psychopathology, self-esteem. locus of control and treatment utilization. All groups were highfy elevated on measures of psychopathology. There were no differences between groups on psychopathology measures, except that the loo:‘,;, group scored significantly higher than the uncompensated group on hostility. Differences in locus of control were not found. On 3 of IO subscales. partially compensated patients reported higher levels of self-esteem than patients in one or both of the other groups. Uncompensated patients required the most hospitalization. Those who were receiving 1000, disability compensation required less hospitalization and the number of days they spent in the hospital was significantly reduced following attainment of full compen-
sation
Disability payments to emotionally disabled individuals through governmental sources such as Social Security and Veterans Administration compensation amount to vast sums of money. In 1978 the VA paid a total of S5.077.000,000 in disability compensation to 2,258.OOO physically and psychiatrically impaired individuals whose disabilities were incurred or aggravated while they were in the service [I]. While the intent of this policy is humane. it has been criticized for creating so much secondary gain that the recipients may resist therapy and rehabilitation, resulting in prolonged or permanent disability. There is a surprising scarcity of research literature on this topic. There have been no systematic research studies investigating the effects of the Veterans Administration compensation system on the personality and behavior of compensated veterans. Much of the literature existing concerning compensation focuses on physical rather than psychiatric disability. In a review article. Carnes [2] concluded that the evidence suggests that individuals with “hypochondriacally organized personalities” were nearly always rehabilitation failures. In a well controlled study with 56 chronic psychotic patients. Griffiths [3] showed that low self-confidence. lack of drive and an attitude that the disability was serious were predictive of poor response to rehabilitative efforts. Similar findings are reported by Campbell er nl. [4]. In a study of post-hospitalization adjustment of schizophrenics. Lorei and Gurel [S] found that employment histor!. was the best predictor of postdischarg,e employment and that number of previous hospitahzations was the best prognosticator of readmission. Walker and McCourt [6] found no association between work in the hospital and subsequent employment outside of the hospital. Ruesch and Brodsk\- [7] focused on the concept of social disabilit>. The! state that impairment is a function of the person. but disability is a function of the social Requests for reprints should be addressed to: Marvin W. K;ahn. Department of Ps!cholo_g~. University of Arizona. Tucson. AZ 85’21. U.S.A. \‘\I
I- -
,
439
situation. Ruesch [83 emphasized that the primary goal of psychiatric hospitalization is social rehabilitation, not undoing psychopathology. More recently Weinstein [9] has detailed stages of what he calls the “disability process”. He concludes that persons who become enmeshed in .this process are typically highly dependent. When difficult circumstances arise or support is withdrawn, they tend to experience a precipitous drop in productivity and self-esteem. Then explanatory events such as injury or illness occur and are used as a rationalization for the decline in competence. Treatment fails and the disability stabilizes, leading to increased dependency and decreased tension. Job productivity drops off entirely but self-esteem returns to a higher level as an ‘honorable disability’ becomes firmly entrenched. Weinstein’s model appears to fit a number of other studies including those of Hirschfield and Behan [IO]. Brodsky [l l] and Martin [12]. In general these studies suggest that people who become involved in a compensation system may resist attempts at rehabilitation. Typically they are passive, dependent, unmotivated, guilty, anxious individuals who are prone to depression. They tend to be poorly educated, unmarried people with backgrounds replete with unstable family relationships, poverty, alcohol abuse, job failure and multiple social problems. Further, they tend to avoid dealing with internal problems, focus blame for their difficulties on external forces and resist cure tenaciously, treating helping professionals with hostility and seeking out people who believe they are permanently disabled. One aspect of the present study was to investigate the applicability of Weinstein’s concept of the disability process to psychiatrically impaired veterans. While a psychiatric disability may not be considered as honorable as a physical disability. it does potentially provide considerable secondary gain. Chronically psychotic individuals typically are treated gingerly and taken care of by family members who fear provoking additional psychotic breaks. However. psychiatrically impaired veterans are sometimes forced to work hard fo secure and main-
440
JOSEPH
L.
PERL
and
tain disability benefits. They must prove the severity of their impairment with frequent hospitalizations, visits to outpatient therapists. unemployment and yearly rating exams. Once declared disabled some continue to struggle to achieve ‘permanently and totally disabled’ status and collect 1007; service-connected disability payments (as of January 1979. $810 per month tax free). The process of seeking full compensation can last many years. Other sources of income. most notably Social Security disability payments, are available to supplement the VA compensation. Two studies have looked at service connection as a variable in compensation research. Walker and McCourt [6] found no association between service connection and post-discharge employment but Lorei and Gurel [S] found that veterans receiving the largest compensation checks were least likely to find jobs after hospital discharge. Thus far, however. there has been no study which has systematically compared groups receiving different amounts of compensation. The purpose of the present study was to examine the impact of the VA compensation system on selected aspects of the personality and behavior of psychiatrically disabled veterans. Psychiatric patients receiving full, partial and no disability compensation were investigated. Among the questions addressed in the study were: (1) What is the relationship of the degree of psychopathology of a given individual to the amount of compensation and level of disability rating? (2) How is a patient’s level of self-esteem related to the level of compensation they receive? (3) What is the association between level of compensation and ‘the patient’s utilization of outpatient and inpatient treatment facilities?
MARVI\
W.
KAHS
l(NO, yroup. This group was composed of 26 individuals. each of whom had been receiving IUO”,, service-connected compensation payments for at least the last 5 years. 1ww,> group. This group was comprised of 31 psychiatrically disabled subjects. each of whom had been receiving between IO”,, and 90”,, serGce-connetted compensation payments for a minimum of the past 5 years. Fluctuation in disability rating was permissible in this group as long as the amount of disability remained within the l&90”. range. Uncornpertsated yroup. This group was composed of 24 psychiatrically impaired patients who. over the last five years, received no compensation for their disabilities from the Veterans Administration. Procedures Each subject was administered an assessment battery which consisted of the Rotter Locus of Control Scale [ 131, the Tennessee Self Concept Scale [ 141. the Symptom Checklist-90-Revised (SCL-90-R) [ 151 the Minnesota Multiphasic Personality Inventory [ 161 and a 72 item demographic questionnaire developed for this study. The demographic questionnaire included items about marital and employment status. educational background. attitudes toward the respondent’s treatment and other topics. In addition. a search of each patient’s medical records was carried out to obtain indices of the patient’s help-seeking behavior including hospital utilization and number of outpatient psychotherapy visits. For the most part, one-way analysis of variance procedures were employed to compare the three groups on the assessment measures. When such analyses revealed that a significant difference existed, a Scheffe post-hoc contrast test was conducted to determine the source of the difference.
METHOD
RESULTS
Subjects
Participatiorl
Subjects were recruited from among psychiatric outpatients seen at a mental hygiene clinic of a Veterans Administration Medical Center. All were male veterans between the ages of 26 and 72, who had a psychiatric diagnosis (either neurosis or psychosis) documented in their hospital records. Of 154 veterans who were approached, 71 agreed to participate. The subjects were classified according to amount of compensation, lOOS/,, l&90% and uncompensated. There were two overriding reasons that veterans receiving 10-90’4 compensation were grouped together, despite what appears to be a wide range of disability payments, and those receiving 100% payments were placed in a separate group. The difference in monetary benefits between 10% status ($44 as of I January 1979) and the 90% category ($450) is only slightly larger than the relatively dramatic leap from 90% ($450) to 100% ($809) compensation status. In addition, there may well be an equally imposing psychological gap between 90 and 100% disability as loom/, disabled veterans, unlike their status, counterparts in the l(r90°/0 range, are declared ‘totally disabled’ or ‘totally and permanently disabled and are assumed to be incapable of maintaining employment. The composition of each group follows,
Somewhat under 50% of those who were approached regarding participation in the study volunteered to do so. The level of compensation being received was related to willingness to participate. Those receiving compensation tended to be less likely to volunteer than those who were not, though this comparison approached significance only CZ’ (I) = 2.84, P < 0.11. Forty percent of those with 100% disability volunteered, 43.8% with partial disability volunteered, while 51.5% of the uncompensated veterans did so. Demogruphic Jactors The three groups were not significantly different in age (mean age was 50.2 years). religion. education. marital history or alcohol-drug abuse history. Furthermore, the proportion of patients diagnosed psychotic vs neurotic in each of the three groups was not significantly different. Chi square tests revealed that subjects in the fully compensated group were significantly more likely to have been unemployed throughout the past 5 years than members of the other groups [x’ (4) = 13.95. P < O.Ol], whereas partially compensated group members were significantly most likely to have held a job throughout the past 5
The effects of compensation
on psychiatric disability
441
Table I. Significant analyses of variance for personality questionnaire scales Variable
Source
d.f.
SS
Between groups Within groups
2 68
781.54 6235.64
Total
70
7017.18
Between groups Within groups
2 68
8484.55 92.874.04
Total
70
101.358.59
Moral-Ethical Self Concept (Tennessee Self Concept)
Between groups Within groups
2 68
869~47 5392.73
Total
70
6262.20
Family Self Concept (Tennessee Self Concept)
Between groups Within groups
2 68
I 136.42 5990.23
Total
70
7 126.65
Hostility (SCL-90-R)
Total Self Concept (Tennessee Self Concept)
MS
F
390.77 4.26* 91.77
4242.27 3.1 I * 1365.79
434.73 79.30
5.48t
568.20 88.09
6.45t
*P < 0.05; tP < 0.001. years. The fully compensated veterans were significantly more likely to have done volunteer work outside the VA than were the other two groups [x2 (2) = 10.91. P < 0.011. Psychopotholog~ aud compensation The MMPI mean profiles for all three groups were indicative of very severe psychopathology. For all three groups there were gross elevations, with group means peaking on the schizophrenia and depression scales. However, there were no significant differences among the groups on any of the three validity or ten clinical scales and profile patterns were almost identical for all three groups. On the SCL-90-R the three groups again had very similar profile patterns which were elevated and very similar to the normative profile for this test for psychiatric outpatients. There was one significant difference among the groups on the ten SCL-90-R subscales. that being on the hostility subscale. The 100% compensation group scored significantly higher on hostility than the uncompensated group as indicated in Table 1.
All three groups indicated very poor self concepts as compared to normative data for the Tennessee Self Concept Scale [ 14). This was true for all subscales. There were. however. significant differences on three self-esteem subscales; total self concept, moral-ethical self concept and family self concept. Subjects in the partially compensated group reported possessing significantly more positive self concepts than IOOY, compensation group members on all three of these subscales and than subjects in the uncompensated group on the moral-ethical subscale.
As a whole. the subject sample generated a mean score (9.61) that was somewhat external when compared with normative data [ 131. Contrary to expectation. self-perceived locus of control was not related to
the amount of compensation being received. The group means were as follows (the higher the score, the more external): 100% group, 10.92 (SD = 5.23); IO-90% group, 8.14 (SD = 4.60); uncompensated group 9.42 (SD = 3.72). Compensation and treatment variables Compensation level and treatment. A comparison of the number of psychiatric outpatient therapy visits made during the past 5 years indicated no differences in outpatient utilization as a function of compensation level. The means for all three groups were approx. 25 visits. However, with regard to hospitalization during the past 5 years, there were significant differences. Because of extreme scores and the resultant large standard deviations (larger than the means), the Kruskal-Wallis one-way analysis of variance, a non-parametric test, was used to analyze three related hospitalization variables: number of hospitalizations in the past 5 years, number of 21 day hospitalizations in the past 5 years (veterans who are lO-90% service-connected are entitled to temporary 100’4 compensation payments for the time they are hospitalized if their stay in the hospital exceeds 21 days), and the total number of days spent in the hospital during the last 5 years. The latter analysis (total hospital days), corrected for ties, produced a statistically significant difference (x2 = 8.34, P < 0.05). The mean ranks were 44.9 for the uncompensated group (mean = 56.79 days, SD = 92.51), 31.5 for the 100% group (mean = 18.04 days, SD = 39.37), and 31.5 for the l&90% group (mean = 23.57 days, SD = 55.88). Thus, subjects in the uncompensated group spent significantly more days in the hospital than subjects in either of the other two groups. The IO-90% group and the 100% group did not differ from each other on this dimension. The same pattern of results held true for number of hospitalizations in the last 5 years (x2 = 7.02, P c 0.05).
442
JOSEPH L. PERL and MARVIS W. KAH\
In sum. it was demonstrated that, in the past 5 years, subjects in the uncompensated group were hospitalized significantly more times and for longer periods of time than were the subjects in either of the two compensated groups. Compensated increase and treatment usage. When compensation increases were to other than a loo”/, rating, there were no differences in either the number of outpatient therapy visits or days spent in the hospital in the years before and after increases. Nor were there any differences in the number of outpatient therapy visits made in the year before and the year after veterans in the 100% group obtained their loo”/; disability rating. However, a matched sample t-test for 22 subjects contrasting the number of days spent in the hospital in the year before members of the 100’4 group obtained a 100’~ disability rating with the number of days spent in the hospital in the year after this change revealed a significant difference (t = 2.75, d.f. = 21, two-tailed P < 0.01). Members of the 100% group spent significantly more days in the hospital in the year prior to obtaining their 100% disability rating (mean = 108.82 days, SD = 101.71) than in the year after attaining a 100’4 rating (mean = 37.73 days, SD = 59.63). Another matched sample t-test was used to compare days spent in the hospital in the years before and after the 100% rating was declared permanent (no longer subject to reduction). Even though data from only 9 subjects were available for this analysis, a significant difference emerged (t = 2.45. d.f. = 8, P < 0.05). Significantly more days were spent in the hospital in the year before the 100% rating was made permanent (mean = 109.89, SD = 135.94) than in the year after (mean = 9.22. SD = 21.22). DISCUSSION
In terms of the focal questions addressed by this study, the findings were surprising. There was no significant association between degree of psychological distress or psychopathology and level of compensation. The degree of psychopathology was extreme, but not different, for all groups regardless of whether or not they received compensation, and regardless of the level of compensation. Thus, compensation for psychiatric disability, in this situation at least, would seem to be based on factors other than degree of psychopathology. Degree of psychopathology may be a necessary but not sufficient basis for establishing disability levels, or it could be that the judgement process is arbitrary and very unreliable, or even that psychopathology is not the crucial factor in the judgement. But if psychiatric disability rating is not based on degree of psychopathology, what is the basis and should this not be made explicit? The only factor of psychopathology that did differentiate among the groups was the hostility scale of the SCL-90-R. Hostility was significantly greater for the 100% compensation group than for the uncompensated group. This would be consistent with a hypothesis that the ability to express hostility may be a crucial factor in obtaing full psychiatric disability compensation. (Perhaps the VA compensation system provides the ‘squeaky wheel’ with the largest dis-
ability checks.) If this hypothesis Lvere true. it could help explain the lack of association between degree ot psychopathology and level of compensation. Alternatively. the dependency that results from almost total reliance on government funds to ensure financial security might engender hostility in the recipients of 1009; disability benefits. However. since the hostility variable was the only one of many comparisons to reach statistical significance. it may reflect only a chance difference. In attempting to understand the overall lack of association between degree of psychopathology and level of compensation. it should be noted that the measures used here were self report measures. Perhaps other or more sensitive measures would show the more expected differences among the groups, These measures are. however. widely used and validated. The second question addressed by the study concerned the relationship between a patient’s level of self-esteem and the level of compensation which the patient receives. Based on Weinstein’s model. it was hypothesized that those receiving 100°, disability compensation would demonstrate the highest level of self-esteem since their disabilities, initially associated with decreased self-esteem, had been socially sanctioned and achieved the status of ‘honorable disabilities’. Results were contrary to expectation. Whereas all groups indicated very poor self regard. the partially compensated group was higher than one or both of the other groups on three of the ten selfesteem subscales. A possible posr-hoc explanation hinges on the fact that partially compensated veterans have not been declared totally disabled and unemployable. but have been given confirmation of impairment. Thus. productivity should not jeorpardize the disability rating and is apt to be valued by the veterans and significant others as it persists despite decreased expections. Enhanced self-esteem is a likely offshoot of continued productivity in spite of a validated disability. The data showing that partially compensated veterans were significantly more likely to have held a job throughout the past five years than subjects in the other groups lends further credence to this explanation. The relatively low self-esteem reported by loo”, group members may reflect the fact that psychiatric disabilities are poorly understood in this society and not viewed as ‘honorable disabilities’ in the same way as are physical injuries incurred in the service. Thus, total psychiatric disability may lead to social rejection rather than social sanction and to increased defensiveness instead of enhanced self-esteem. On the other end of the continuum. uncompensated group members’ unsuccessful pursuit of validation of their disabled status may engender a poor self concept. In terms of the third and last question raised by this study, the findings concerning the relationship between the amount of hospitalization and compensation status are of considerable note. Conventional logic would suggest that those who have been judged loo”,” disabled would require the most hospitalization, while those who have not been given a disability rating would require the least. The data show just the opposite. Those without compensation were hospitalized significantly more often and for longer
The effects of compensation periods than were those with compensation. Utilizing Weinstein’s ‘disability process’ schema, uncompensated veterans. despite their documented diagnoses. mav be locked in an ongoing struggle to demonstrate the extent of their impairment and to achieve ‘honorably disabled’ status. It would follow that a way to reduce hospitalization for psychiatric disability under the present system is to grant compensation for the disability. However. results of the present study also indicate that a lOO:, disability rating based on a psychiatric disorder is associated with diminished selfesteem. This may be particularly true in a nation in which the work ethic is highly valued and psychological distress is not well accepted or understood. For those veterans receiving compensation, increases in disability status to other than a 100% rating were not associated with any changes in inpatient or outpatient hospital utilization rates. However, the attainment of a lOOo/0disability rating was related to a significant decrease in the amount of time spent in the hospital during the following year. This striking finding highlights the potent impact of the VA compensation system and speaks to the financial and psychological meaning of a 100% rating. The achievement of ‘total disability’ status and especially ‘total and permanent disability’ status may engender a reduced sense of financial and emotional stress and/or a lowered need to demonstrate the extent of the disability. The latter conclusion is supported by the fact that the rating boards which make decisions on compensation status almost always consider the number of days veterans spent in the hospital, but rarely have access to data on outpatient visits (a variable which appeared impervious to change in this study). As long as there is a compensation system for emotional disability, the present results suggest that, from an economic point of view, granting disability compensation may be less expensive than the cost of the high rate of hospitalization which occurs without it. However, the self-esteem data should serve as a warning that deleterious psychological consequences may result from attainment of total disability status. Further research is needed to look more closely at the economic and phychological costs and benefits of the VA compensation s_ystem. As disability compensation
on psychiatric disability
443
programs continue to flourish, they must be scrutinized to ascertain the bases for ratings decisions and to determine whether such programs arc actually enhancing or impeding rehabilitative efforts. REFERENCES
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