Recently, a veteran I am treating for severe posttraumatic stress disorder (PTSD) came to her appointment in tears. “They say I’m not able to handle my money, and they want my husband to be in charge of my benefits.”

After some deep breathing exercises, we discussed the situation. My patient was upset, not because she didn’t trust her husband, but because she felt judged by the Veterans Benefits Administration (VBA). “They said I’m incompetent. But I’m a grown woman, and I’ve been taking care of myself my whole life.”

The situation was exacerbated by the shock of the notification. She had not been told during her Compensation and Pension Exam that the examiner could make a statement about her ability to handle her funds, and in the excitement of her initial benefit award, she had not carefully read the paperwork she received about fiduciaries. When we looked at this paperwork together, we found that VBA had indeed told her that she was being considered for a fiduciary, based on the examiner’s evaluation, and that she should notify them within 90 days if she wished to contest this. When they did not hear from her after 90 days, they had proceeded with the fiduciary process.

More than 100,000 individuals receiving VBA benefits have fiduciaries—trustees assigned by VBA to directly receive and disburse disability funds to beneficiaries the VBA believes are unable to manage their own finances. My interest in fiduciaries began while I was working at the Durham VA Psychosocial Rehabilitation and Recovery Center in North Carolina under the directorship of Daniel Bradford, MD. In this clinic, which focuses on helping veterans with severe mental illness achieve personal goals and wellness, many of the veterans had fiduciaries. For some veterans, this was immensely beneficial, whereas for others, it was highly problematic. In either case, clinicians frequently felt left out of the loop. Because the fiduciary process is managed through VBA, not the VHA , fiduciaries can be assigned, changed, or discontinued without clinicians knowing anything about it. The process is sometimes complicated, and at the time, I was unable to find a resource that provided a simple overview of the system. In the face of a seemingly mysterious institution, I, like many other clinicians, avoided discussing the details of financial capacity with my patients.

This, however, does not have to be the case. A recent article published in the January 2015 issue of Federal Practitioner, “Fiduciary Services for Veterans With Psychiatric Disabilities,” written by myself and coauthored by Eric Elbogen, PhD, and Lorna Moser, PhD, helps clinicians understand the basic steps in the fiduciary assignment process, how this process may affect veterans who have fiduciaries, and the differences that exist between the Social Security Administration and the VBA.

VA clinicians who are informed about the VBA fiduciary process can play an important role in veterans’ experiences of fiduciaries. Clinicians can reduce the stigma associated with fiduciaries, educate their patients about the fiduciary’s role, and facilitate a positive relationship between the fiduciary and the patient. They can document clinical findings in their notes to provide evidence of the level of their patients’ financial capacity. They can also be vigilant for any evidence of exploitation of the veteran or misuse of his or her funds. Although misuse is uncommon, it is important to remember that a clinician may be one of the few people able to advocate actively on the veteran’s behalf if such an unfortunate event occurs.

In the case of the patient described earlier, I was able to educate her about fiduciaries, clarify what had already happened, and describe what she should expect next. I provided her with information from the VA fiduciary program website (http://benefits.va.gov/fiduciary) and contact information for her Regional Benefit Office. We discussed the pros and cons of having a fiduciary, and she decided she wanted to appeal the decision. I offered to refer her to our Neuropsychological Testing Unit for a financial capacity evaluation and explained how these results might help us get a better picture of her financial competence. She did not want to pursue this immediately, so I suggested we keep it in mind as a future option. She was able to leave the office calmly, with a plan for how she was going to deal with her current situation.

Regardless of the eventual outcome of her case, I believe the experience of deciding on a goal and formulating active steps toward it will be beneficial for her mental health recovery. As a clinician, my improved understanding of the fiduciary system provided me with the opportunity for a positive clinical outcome that might otherwise have been lost.

Have a comment? E-mail fedprac@frontlinemedcom.com.

Navigating the VBA Fiduciary System One Patient at a Time

Christine M. Wilder, MD