Substance Use & Misuse, 48:922–932, 2013
C 2013 Informa Healthcare USA, Inc.
Copyright ISSN: 1082-6084 print / 1532-2491 online
DOI: 10.3109/10826084.2013.797468
ORIGINAL ARTICLE
Catch, Treat, and Release: Veteran Treatment Courts Address the
Challenges of Returning Home
Michelle Slattery1,2 , Mallory Tascha Dugger1 , Theodore A. Lamb2 and Laura Williams3
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1
Trauma, Health & Hazards Center, UCCS, Colorado Springs, Colorado, USA; 2 Peak Research, Colorado Springs,
Colorado, USA; 3 Office of Behavioral Health, Colorado Department of Human Services, Denver, Colorado, USA
of these disorders have known links to other challenges,
which pose an increased risk of justice-involvement for
veterans, including unemployment, homelessness, the use
of illegal drugs, and alcohol misuse (BLS Report, 2011;
Institute of Medicine, 2010, 2012). A wide range of studies suggest a correlation between combat trauma and
criminal behavior (Noonan & Mumola, 2004; Rand Report, 2008; Wilson & Zigelbaum, 1983). The National
Vietnam Veterans Readjustment Study (Kulka et al.,
1990), for example, found that nearly half of male combat
veterans who suffered from PTSD had been incarcerated
one or more times.
Veteran Treatment Courts (VTCs) offer a “circle the
wagons” approach as they provide access to treatment for
mental health challenges, linkage to services to help participants obtain housing and employment, peer mentors
for guidance and encouragement, and intensive supervision and accountability to help justice-involved veterans
transition back to useful and productive lives.
The VTCs may serve justice-involved veterans and
active-duty military service members with misdemeanor
and/or felony charges. Some VTCs require participants
to plead guilty before beginning the program with intensive requirements of supervised probation, mental health
treatment, substance use monitoring, and frequent court
appearances. Veterans choose VTC participation over traditional paths to justice involving criminal trials and possible incarceration, with the intention of graduating, having their sentences deferred, their charges reduced, and/or
records sealed. Sealing a felony conviction effectively
After a decade of war, there is a great need for treatment and alternatives to incarceration for justiceinvolved veterans. U.S. military service members are
returning from combat with substantial mental health
challenges, which increase the potential for justice
involvement. Veteran Treatment Courts are starting
across the nation to meet this need for therapeutic
justice. These problem solving courts provide access
to treatment and motivation for engagement. Preliminary evidence from a Substance Abuse and Mental Health Services Administration-funded evaluation
suggests that significant improvements in posttraumatic stress disorder and substance use are just a few
of the positive outcomes that these courts may help
veterans achieve.
Keywords Veteran Treatment Court, substance use, PTSD, TBI,
employment, housing, U.S. military, OEF/OIF, justice,
SAMHSA
There is a great need for treatment and alternatives to
incarceration for veterans. More than 2.2 million Americans have deployed to Iraq, Afghanistan, or both since October 2001 (Substance Abuse and Mental Health Services
Administration [SAMHSA], 2012a). Research suggests
that these veterans are returning with substantial mental health challenges including posttraumatic stress disorder (PTSD), increased risk of suicide, traumatic brain
injury (TBI), and depression (ARMY Gold Book, 2012;
Hoge et al., 2004; MSMR, 2010; Rand Report, 2008). All
The authors would like to thank the entire Colorado 4th Judicial District Veteran Trauma Court team: Judges David Shakes and Ronald Crowder;
Public Defenders Sheilagh McAteer and Deana O’Riley; District Attorneys Jeff Lindsey, Brian Cecil, Rick Mattoon, John Russo, and former DA
Doug Miles; Court Clerks Kim Kafel, Kathy Corcoran, Diane Stecco, and Gwen Prater; Probation Officers LaTonya Scott and Alvaro Corral;
Probation Supervisors Kurt Runge, Kristen Hilkey, Julian Cortez, and Ron Miller; Former Coordinator Carrie Bailey and Assistant Coordinator
Maria Eagan; Peer Mentors Leo Martinez, Rich Lindsey, Nicholas Brown, Dennis McCormack, Michael Chumbler, John Hill, Dabney Vance, and
Jose Espinosa; VA VJOs Laura Sales and Mike Ott; the Colorado Division of Behavioral Health, including Grant Specialists Laura Wildt and Deb
Hutson; TBI and Trauma Expert/Trainer Marguerite McCormack; the UCCS Trauma, Health & Hazards Center team, including Debbie Sagen,
Justin Miller, Raine Lamb, Gina Tambone, Victoria Garcia, Perla Abarca, Elyse Dunckley, Nicole Emmons, and Chip Benight; the national
evaluation team at Advocates for Human Potential, including Laura Elwyn, Kristin Stainbrook, Joli Brown, and Andy Klein; Steve Sullivan at
Cloudburst; Dave Morrissette at SAMHSA; and the generous veterans who agreed to participate in this study to help other veterans.
Address correspondence to Michelle Slattery, Trauma, Health & Hazards Center, UCCS, 1420 Austin Bluffs Parkway, Colorado Springs, CO 80918,
USA or Peak Research, 7712 Eastwood Road, Colorado Springs, CO 80919 USA; E-mail: peakresearch@usa.net
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VETERAN TREATMENT COURTS CATCH, TREAT, AND RELEASE
erases it, allowing the participant a fresh start, as though
the conviction never occurred.
The ability of VTCs to seal felony convictions provides
substantial incentive to participate and engage in treatment. Evidence-based practices, such as prolonged exposure therapy and cognitive processing therapy for PTSD,
are encouraged. If participants fail to engage in treatment,
sanctions are recommended by the Court Team. A key feature of some VTCs is staffings attended prior to the docket
each week by a Court Team that consists of a VA Veteran’s
Justice Outreach specialist, private therapists, Army Behavioral Health team, the presiding Judge, District Attorney, Public Defender, Probation Officers, peer mentors,
and an evaluator.
The VTCs are often modeled on other specialty courts,
such as drug courts, with a wide range of methodologies, policies, and procedures. VTCs may feature different
intercept points for participants and may allow different
types of charges, but most follow the foundational tenets
of drug courts to address risk factors for criminal behavior that might result in additional justice involvement
(Russell, 2009b). When veterans succeed in these courts,
communities also win as recidivism for these types of
courts is expected to be lower than traditional paths to justice and equal to or better than drug courts (Holbrook &
Anderson, 2011).
The VTCs are growing in number at three times the
rate that Drug Courts grew 20 years ago (National Association of Drug Court Professionals [NADCP], 2010). The
first was started in 2004 in Anchorage, Alaska (Holbrook
& Anderson, 2011), but the court credited with providing
the inspiration for the current surge of VTCs was started
by Judge Robert Russell in 2008 in Buffalo, New York
(Russell, 2009a). Today, there are more than 100 VTCs
in America, with more than 200 in the planning stages
(NADCP, 2012). Public support appears to be growing for
the idea of a second chance for justice-involved veterans
with mental health and substance use disorders resulting
from military service trauma.
Thirteen states, including Colorado, received 5-year
SAMHSA grants in 2008 and 2009 to help fund the design, development, and implementation of pilot VTCs
(SAMHSA, 2008). These grantees were also tasked with
working with groups statewide on legislation, infrastructure, sustainability, training on trauma-informed care, and
laying the groundwork to roll out VTCs statewide. Importantly, comprehensive evaluations of these courts were required and are now starting to yield results, like this study,
which may help others understand the potential impact of
VTCs in their communities.
The present study reports the preliminary results of participation in a pilot VTC on veterans with PTSD and/or
TBI. The purpose of this study was threefold: (1) establish rates of PTSD, TBI, and substance use among VTC
participants; (2) explore veteran experiences, comorbidity, and participation outcomes; and (3) discuss the VTC
model, what works, why, and where it achieves its greatest
impact. The remainder of this introduction describes the
PTSD, TBI, and substance use problems many veterans
are facing.
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PTSD
According to the Department of Veterans Affairs (VA),
one in five “Operation Enduring Freedom” (Afghanistan)
and “Operation Iraqi Freedom” (OEF/OIF) veterans in
their care has symptoms of a mental health disorder
(SAMHSA, 2012a). PTSD was first classified as a mental health disorder in 1980 in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., text rev.; DSMIII; American Psychiatric Association, 1980). It is defined
as a mental disorder resulting from exposure to an extreme, traumatic stressor, and features symptoms of reexperiencing, avoidance and numbing, and/or increased
arousal. Published rates of PTSD prevalence for OEF/OIF
veterans vary in the literature (e.g., Hoge et al., 2004;
Milliken, Auchterlonie, & Hoge, 2007; Ramchand et al.,
2010; Rand Report, 2008), ranging from approximately
13% to 35%. PTSD is associated with cooccurring disorders, such as TBI, substance use disorders, and depression (Pietrzak, Goldstein, Southwick, & Grant, 2011).
Research shows that veterans with PTSD suffer from
poorer overall health, greater use of alcohol and drugs
over their lifetimes, and more justice involvement than
their peers without PTSD (Saxon et al., 2001). A PTSD diagnosis makes a veteran four times more likely to report
thoughts of suicide than veterans without a PTSD diagnosis (Jakupcak et al., 2009) and 14.9 times more likely
to attempt suicide than peers without a PTSD diagnosis
(Davidson, Hughes, Blazer, & George, 1991).
Discharged and retired veterans of OEF/OIF have twice
the risk of PTSD of active-duty warriors (Schell & Marshall, 2008), suggesting that there may be a lag in the time
to trouble for the development of PTSD symptoms, as was
found in research on Vietnam era veterans that took place
10–20 years after combat (Kulka et al., 1990). Rates of
PTSD also seem to increase with time. Seal et al. (2011)
used VA data to discover a more than 21% increase in
PTSD from 2001 to 2008. Stigma surrounding care may
also limit early diagnosis (cited in Friedman, 2004). It may
be too early to understand the full magnitude of post-911
era combat experiences on veterans.
TBI
Traumatic brain injury is defined by the Centers for Disease Control and Prevention (CDC, 2003) as “an injury caused by a blow or jolt to the head or a penetrating head injury that disrupts the normal function of the
brain.” TBI has become a “signature injury” of the wars
in Afghanistan and Iraq because of the large number of
injuries sustained by contact with improvised explosive
devices and also because the wounded are surviving their
brain injuries.
Findings by the Committee on the Initial Assessment
of Readjustment Needs of Military Personnel (2010, as
cited in Army Gold Book, 2012) show that veterans of
OEF/OIF have a “fatality to wounded ratio of 1:5.0 and
1:7.2 as of November 2009, compared with a Vietnam
ratio of 1:2.6.” Veterans wounded in our most recent
conflicts are surviving at a higher rate, creating additional
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M. SLATTERY ET AL.
challenges for diagnosis and treatment. The VA began
screening procedures for mild TBI in 2007, consisting of
questions that are required to be asked of all OEF/OIF
veterans who seek care at VA medical facilities (GAO,
2008). This action may improve our understanding of the
true rate of TBI among veterans in the future.
Estimates of the incidence of mild TBI vary from study
to study, ranging from 10% (Stein and McAllister, 2009)
to 19% (Rand Report, 2008). Severe brain trauma is reported in 25% of service members evacuated from Iraq &
Afghanistan (NADCP, 2010).
According to Hoge et al. (2008), PTSD is strongly
associated with TBI. They found that 43.9% of soldiers
with a reported loss of consciousness met the criteria for
PTSD, compared with 9.1% of soldiers with no injuries
and 16.2% of soldiers with other injuries.
Substance Use
Substance abuse is often described as “the single greatest predictive factor for the incarceration of veterans”
(Drug Policy Alliance, 2009) because of recent studies
(Erickson, Rosenheck, Trestman, Ford, & Desai 2008).
According to the annual SAMHSA National Survey on
Drug Use and Health (SAMHSA, 2012b), the rate of illicit drug use among Americans is 8.7%. For criminal justice populations, rates of illicit drug use increase to 26.5%.
It is estimated that 60% of veterans in U.S. prisons have
substance use disorders (NADCP, 2010). The Bureau of
Justice Statistics (Mumola, 2000) reports that 81% of
justice-involved veterans had a substance abuse problem
prior to incarceration. The National Center for PTSD
(2010) reports that many veterans use alcohol to selfmedicate.
The PTSD and substance use disorders are often dually diagnosed, with estimates ranging from 19% to 58%
(cited in Reynolds et al., 2005). Research shows that when
PTSD improves there are also better substance use outcomes; however, improvement in substance use disorders does not make PTSD better (Ouimette, Brown, &
Najavits, 1998).
Other Challenges
The PTSD, TBI, and substance use disorders have known
links to other challenges, which pose an increased risk
of justice-involvement for veterans, including unemployment, homelessness, and suicide risk. The unemployment
rate for OEF/OIF veterans was 12.1% in 2011 (BLS Report, 2011), compared with 7.8% for the general population today. The national rate of homelessness is 21
homeless people per 10,000 people in the general population, whereas for veterans it is 31 homeless veterans per
10,000 veterans in the general population for the period
2009–2011 (State of Homelessness in America, 2012).
A veteran commits suicide in this country about every
80 minutes (Army Times, 2010). According to “Invisible
Wounds of War,” a report released in 2008 by the RAND
Corporation, increasing numbers of veterans are returning from combat with mental health issues for which they
do not seek treatment, placing them at a higher risk for
justice involvement. Thoughts of suicide are more prevalent among veterans with PTSD (Jakupcak et al., 2009).
Readjustment to civilian life may be challenging for all
of the reasons previously cited, but dwindling news coverage and the fact that few Americans have served in the
military during these conflicts has contributed to the perception by both post/911 veterans and the public that there
is “little or no understanding” of the challenges faced by
the military (Pew, 2011).
METHODS
Participants
Study participants are 83 individuals who agreed to participate in the evaluation of the VTC in Colorado Springs
over a period of 3 years. Eighty percent are separated from
service (veterans); 20% are still in the military (active
duty) at Baseline. Participants are primarily White (76%),
male (95%), U.S. Army (93%), OEF/OIF Era (88%) warriors who have served an average of two tours of duty in
combat theater (95%). Mean age is just under 30 years.
Educational level is high, with 63% reporting “some college” or more education. Just 2% of participants do not
have at least a high school diploma or GED at Baseline.
Procedures
Participants completed lengthy, 200-item, private, inperson interviews with evaluation researchers at the Court
House during scheduled VTC dockets. Interviews were
completed at Baseline, 6 months, and 12 months. Participants were paid $20 cash after each completed interview,
at each of the three-time intervals, for a total of $60. Informed consent for participation in the VTC, the evaluation of the VTC, and each of the three interviews was
obtained. The University of Colorado Colorado Springs
IRB approved the study.
Measures
Baseline, 6-month, and 12-month interview protocols
were assembled by Advocates for Human Potential
(AHP), the national evaluation team for Jail Diversion
and Trauma Recovery–Priority to Veterans SAMHSA
grantees. Interviews consisted of approximately 200 items
each. Items were grouped into the following categories:
demographics, education, employment, income, military
service, military trauma, lifetime mental health/substance
use service, drug and alcohol use, Cut down, Annoyed, Guilty, Eye-Opener (CAGE), criminal justice,
functioning, social connectedness, traumatic events, PostTraumatic Stress Disorder Checklist Civilians (PCL-C),
the 24-item version of the Behavior and Symptom Identification Scale (BASIS-24), Recovery Markers - Revised,
services used, and perception of care. Sixty-four of these
items were created by and required for Government Performance and Results Act/National Outcomes Measurement System (GPRA/NOMS) compliance (GPRA, 1993).
Military Service/Combat Experience questions were
adapted from several sources, including Rand Monograph items from Invisible Wounds of War (Tanielian &
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VETERAN TREATMENT COURTS CATCH, TREAT, AND RELEASE
Jaycox, 2008) and standard veteran questions from the
United States Census Bureau (2010). The protocol included combat experience items provided in Hoge et al.
(2008), which are tailored to the nature of combat in Iraq
and Afghanistan.
Traumatic Event items were designed to capture early
life (before age 18), adult life (18 or older), and past 6month trauma histories. Items were adapted from the Posttraumatic Diagnostic Scale (Foa, 1995). This instrument
is descriptive only, providing trauma history and information about timing.
The Cut down, Annoyed, Guilty, Eye-Opener instrument is widely used in criminal justice as a quick, easy to
remember screen for alcohol dependence or misuse (Ewing, 1984). The CAGE has four items with a “have you
ever” format. Two positive responses indicate strong potential for substance dependency or abuse (CAGE, 1984).
The VTC participants were also asked to rate the frequency at which they experienced problems related to substance abuse—hiding drug or alcohol use, having the urge
to use, and experiencing problems from use. Ratings were
provided for the past 30 days at 6-month interview and
12-month interview. Ratings were provided on a 5-point
Likert scale from “never” (0), “rarely” (1), “sometimes”
(2), and “often” (3) to “always” (4).
The 24-item version of the Behavior and Symptom
Identification Scale is a widely used, well validated, “measure of self-reported difficulty” of full scale functioning
on six functioning domains, developed at McLean Hospital in Belmont, MA (Idiculla, Speredelozzi, & Miller,
2005). The six subscales have 24 weighted items that yield
subscale scores and an overall 24 item score. Subscales
include depression/functioning, relationships, self-harm,
emotional lability, psychosis, and substance abuse. The responses to the items vary from zero to four. There are five
response options augmented by “Don’t Know” or “Refuse
to Answer.” The answer options vary from “No difficulty”
to “Extreme difficulty,” “None of the time” to “All of the
time,” and “Never” to “Always.”
The PTSD was measured with the PCL-C, a widely
used, well-validated instrument, which consists of 17
items representing three categories of symptoms: “reliving,” “avoidance,” and “arousal.” Response options include “Not at all,” “A little bit,” “Moderately,” “Quite a
bit,” or “Extremely.” Items are rated on a scale from 1 to
5. The scores are summed to determine symptom severity.
The clinical cutoff for PTSD diagnosis is a score of 50 or
above. (Weathers, Litz, Herman, Huska, & Keane, 1993).
Criminal Justice items were adapted from previous
cross-site evaluations of SAMHSA grants by AHP. Six
items address age of first arrest, previous incarcerations,
history of protection orders, and probation history.
Arrest data were accessed from probation Eclipse
databases for prior, target, and one-year post arrest record
tracking.
The 4-Question PTSD Screen was used as a quick
screen for PTSD diagnosis for participants to determine
program eligibility for the District Attorney prior to program start and clinical engagement (Prins et al., 2003).
The Lead Peer Mentor administers this instrument.
The Defense and Veterans Brain Injury Center 3Question TBI Screen (DVBIC3-Q) was used as a quick
screen for TBI diagnosis for participants to determine program eligibility prior to program start. The DVBIC3-Q is
widely used by military organizations as a starting point to
recommend additional testing (Schwab et al., 2006). The
Lead Peer Mentor also administers this instrument.
Limitations of the Study
This analysis presents a longitudinal evaluation of the experiences of one group of veterans. The study does not
include a comparison group to measure what might have
happened had veterans remained within the judicial system. The study is also limited to a single veterans court in
one city, which does not allow for comparisons that would
identify the most effective features of a VTC. Lastly, the
sample size is fairly modest, which restricted identification of smaller effects and the specification of more complex statistical models.
Statistical Analyses
Personal interview data were collected with a mix of paper instruments and QDS (Questionnaire Development
System) computer-assisted personal interview software
loaded onto a laptop computer with PGP Encryption.
SPSS software (version 19.0) was used for data analysis. Descriptive statistics (proportions, means, standard
deviations) were used to describe the overall population
and subgroups on demographic variables. Chi-square tests
were used to assess when differences between groups
were statistically significant. One-way analysis of variance (ANOVA) with repeated measures was used to compare means between the groups and across three-time intervals on the BASIS-24 and the PCL-C.
RESULTS
This section first examines the mental health problems
presented at Baseline and then examines improvement
over time in mental health, substance use, and various
measures of social integration.
Participant Characteristics—PTSD
At Baseline, all study participants (100%) had positive
screens for PTSD on the 4-Question PTSD quick screen
to determine program eligibility. A majority of study participants (80.7%) also met criteria for clinical diagnosis of PTSD on the PCL-C at Baseline. PCL-C scores
that met the clinical level for diagnosis declined from
80.7% at Baseline to 66.7% at 6-month interview, and to
57.8% at 12-month interview (Table 1). PTSD improved
TABLE 1. Percentage of VTC participants with PCL-C DSM-IV
diagnosis for PTSD
Baseline
80.7%
∗
6 months
∗
66.7%
12 months
57.8%∗
Significant reductions from Baseline to 6-month interview and
Baseline to 12-month interview, p < .05).
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M. SLATTERY ET AL.
PCL-C
60
58
58.3
56
54
51.4
52
50
48.7
48
Baseline
6 Month
12 Month
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FIGURE 1. Plot of PCL-C Sum Severity Score means from Baseline to 12-month interview.
significantly (p < .05) from Baseline to 6-month interview. This improvement was sustained after 12 months,
although no further declines were noted between 6 and
12 months.
PTSD Symptoms, Subscales, and Clinical Diagnoses
The PCL-C Sum Severity Scores (Weathers et al., 1993)
were analyzed with a one-way ANOVA for repeated
measures. The results were significant, F (2) = 9.720, p <
.001, n = 40. In addition, pairwise comparisons between
means for the different measurement intervals show that
scores dropped significantly from Baseline to 6-month
interview, with continued, although not significant, improvement from 6- to 12-month interview. Figure 1 plots
Sum Severity Score means across three-time intervals.
Participant Characteristics—TBI
The TBI quick screens were not clear for all participants.
More than a quarter (26.5%) confirmed TBI on the quick
screen at Baseline. Forty-seven percent of participants
did not have positive tests for TBI on the DVBIC quick
screen. More than a quarter (27.4%) had unknown, inconclusive, or missing results. Screens for TBI were administered only at Baseline. One third of participants (32.8%)
with PTSD diagnoses at Baseline also had positive TBI
screens. Twenty-seven percent of veterans and 24% of
active-duty service members had positive TBI screens at
Baseline.
Participant Characteristics—Trauma
Fifty-seven percent of VTC participants had drug or
alcohol-related charges in the arrests that brought them to
the program. Drug- and alcohol-related charges were not
necessarily the most serious charges in the arrests of participants. This finding is likely an artifact of the selection
criteria for the VTC. Fifty-two percent of participants answered two or more CAGE questions positively, indicating “strong potential” for substance abuse or dependence.
Twenty-seven percent reported being engaged in outpatient treatment for alcohol and substance abuse within
the past 30 days at Baseline. Sixteen percent reported inpatient treatment for substance abuse or detox within the
past 30 days at Baseline. No emergency room visits for
alcohol or substance abuse were reported within the past
30 days at Baseline.
Substance Use and Related Behaviors
Ratings show that participants are not hiding drinking or
drug use at 6 or 12 months (Figure 2). They have slightly
more problems from drinking or drug use at 12 months
than at 6 months, but ratings are very low. Participants
struggle most with the urge to drink alcohol or take street
drugs, with the urge slightly greater at 6 months than at 12
months
Participants were also asked to report the frequency of
usage for 10 substances, including alcohol, illegal street
drugs, and prescription drugs not prescribed to them. Alcohol was the #1 substance choice followed by cannabis,
methamphetamine, prescription opioids and sedatives not
prescribed to the individual surveyed, cocaine, and street
opioids (Table 2).
Participants reported substantial declines in use of
alcohol and illegal drugs (Table 3). Alcohol use was
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
6-Months
12-Months
Times You Hid Drinking or Times You Had the Urge to Times You Had Problems
Drug Use
Drink Alcohol or Take from Drinking or Drug Use
Street Drugs
FIGURE 2. Mean ratings of substance use problems at 6 months and 12 months.
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VETERAN TREATMENT COURTS CATCH, TREAT, AND RELEASE
Social Functioning
TABLE 2. Usage and frequency of substances at baseline
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Usage & frequency of
substances at baseline
(past 30 days)
Alcoholic beverages
Cannabis
Cocaine
RX stimulants not
prescribed to you
Methamphetamine
Inhalants
Sedatives not
prescribed to you
Hallucinogens
Street opioids
RX opioids not
prescribed to you
Never
Once or
twice
Weekly
Daily or
almost
daily
57%
76%
97%
99%
26%
11%
1%
1%
14%
4%
1%
0
3%
8%
0
0
94%
100%
96%
3%
0
3%
1%
0
1%
1%
0
0
99%
97%
96%
1%
3%
4%
0
0
0
0
0
0
Social Integration
Note: Totals may not equal 100% due to rounding.
TABLE 3. Alcohol and substance use
Baseline
Any alcohol
use—past
30 days
Any illegal
substance
use—past
30 days
6 months
12 months
44.6%
∗
26.7%
20%
26.5%
11.9%∗
6.7%
Figure 3 presents the BASIS-24 Scale scores. A substantial overall improvement occurred between Baseline and
6-month interview. The results were significant, F (2) =
7.315, p < .001, n = 38. In addition, pairwise comparisons between means for the different measurements and
the plot below show that Full Scale scores dropped significantly (p < .05) from Baseline to 6-month interview and
were sustained at 12 months.
The BASIS-24 subscale scores were also analyzed with
one-way ANOVAs. Only 2 of the 6 subscale scores, relationships and psychosis, did not show significant improvement (p < .05). Table 4 includes the results of these
analyses.
∗
Significant reductions from Baseline to 6-month interview, p <
.05).
Participants experienced some improvement in employment and stability of housing during the study
period, but gains were modest and not significant
(Table 5). Thirty-four percent reported that they were
“unemployed—looking for work” at Baseline, compared
with 28% at 6-month interview and 20% at 12-month
interview.
Seventy percent reported that they lived in their own
homes most of the time in the past 30 days at Baseline. Thirteen percent reported that they lived in institutions, such as a jail or inpatient treatment facility. Thirteen
percent reported “unstable” housing. Four percent were
homeless. Approximately 17% of participants were homeless or unstably housed at Baseline, compared with 15.3%
at 6-month interview and 15.6% at 12-Month interview.
Rates of unstable housing were not significantly different
(p < .05) at Baseline and 6-month interview, Baseline and
12-month interview, or 6- and 12-month interview.
VTC Program Compliance
reported by more than 44% at Baseline but declined significantly by 6 months. This decline in use was sustained
at 12 months. The modest decrease in use between 6 and
12 months was not significant. The same pattern was true
for use of illegal substances, as well, with a steep, significant decline in the first 6 months and then those improvements were sustained. Just 5% of participants reported
binge drinking in the past 30 days of five or more drinks
in 1 day for males or four or more drinks in 1 day for
females.
The average time to graduate from the VTC for the first 32
graduates of the program was 67 weeks, or approximately
17 months. During that time, participants averaged 2.5
treatment appointments per month. The mean number of
total appointments related to VTC participation, however,
was 16 per month during Phase 1, called Engagement,
which typically lasted 120–180 days. These appointments
included court appearances, meetings with Probation Officers, treatment appointments, substance use monitoring such as Urinalysis (UA), Breath Alcohol (BA), and
BASIS-24
1.8
1.6
1.6
1.4
1.3
1.2
1.2
1
Baseline
6 Month
12 Month
FIGURE 3. Plot of BASIS-24 Full Scale score means from Baseline to 12 months.
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M. SLATTERY ET AL.
TABLE 4. BASIS-24 subscale score means baseline to 12 months
BASIS-24 subscale
1. Depression/functioning
2. Relationships
3. Self-harm
4. Emotional lability
5. Psychosis
6. Substance abuse
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∗
Baseline mean
6 month mean
12-month mean
1.8
1.7
0.39
2.5
1.2
0.82
1.4
1.6
0.27
2.1
0.96
0.49
1.4
1.5
0.08
1.9
0.94
0.53
One-way ANOVA repeated measures results
F (2, 39) = 3.877,
F (2, 38) = 1.786,
F (2, 37) = 4.339,
F (2, 40) = 6.613,
F (2, 40) = 2.055,
F (2, 40) = 4.330,
p < .05, n = 41∗
p > .05, n = 40
p < .05, n = 39∗
p < .05, n = 42∗
p > .05, n = 42
p < .05, n = 42∗
Significant at the .05 level, two-tailed.
80-hour alcohol testing (EtG) appointments, as well as
meetings with peer mentors and service providers.
The VTC participants report that they “like the
services” they received from the VTC (86%), “would
recommend” the VTC to others (81%), and the Court
Team believes that they can “grow and change” (91%).
When asked about the impact of peer mentors on their
success in the program, 87% of participants attributed
“some” or “all” of their success to the help they received
from peer mentors. To date, 32% of VTC participants
have graduated from the program and 11% have failed.
Prerelease recidivism is 11%. Postrelease recidivism,
defined as new charges within 1 year of graduation, is
zero. It may be premature to report recidivism as just
10 individuals have been graduated from the VTC for a
period of 1 year or more.
DISCUSSION
This study explored the preliminary results of participation in a pilot VTC on veterans with PTSD and/or TBI.
The purpose of this study was to establish mental health
and substance use challenges among participants and increase understanding of the VTC model.
Rates of PTSD and substance use among justiceinvolved veterans were substantial at program start. Participants also faced other challenges, including high rates
of unemployment and unstable housing or homelessness.
Although VTCs participation did not significantly
improve unstable housing or unemployment, mental
health did improve. Improvements in PTSD, depression,
self-harm, emotional lability, and substance use were significant from Baseline to 6-month interview and sustained
from 6- to 12-month interview. The impact of mental
health and substance use improvements on long-term
justice-involvement should continue to be tracked.
Improvement in PTSD symptoms and severity shows
that the VTC model was both effective and quick in helping veterans on the path to recovery. The high rate of clinTABLE 5. Employment and stability in housing baseline to 12
months
Unemployed—looking for
work
Unstably housed
Baseline
6 months
12 months
34%
28%
20%
17%
15.3%
15.6%
ical PTSD diagnosis at Baseline far exceeded estimates
obtained from a review of the literature, suggesting that
justice-involvement may be more likely for people with
PTSD. This finding makes a strong argument for the existence of VTC as well as the need for their expansion to
provide therapeutic justice to help heal veterans who have
served our country.
The TBI was difficult to assess in a meaningful way.
Quick screens must be replaced by valid and comprehensive clinical assessments before understanding of the role
of TBI on veterans, and cooccurring challenges may be
possible.
More than half of VTC participants had substantial
substance use disorders as measured by the presence of
illegal drugs or alcohol in target arrest reports, results
on CAGE items, self-reports of use, and BASIS-24 subscale scores. The use of alcohol and cannabis to “selfmedicate” may explain the prevalence of use at Baseline.
Once connected to treatment, which may include prescription medications, use of all substances dropped significantly and was sustained through the first year of participation. Again, the VTC model was effective at providing
alternatives to alcohol and illegal substance use.
What happened to veterans during the 6-month window from Baseline interview to 6-month interview that
allowed them to start healing and begin to curtail behaviors that may have been negatively impacting their lives?
One possibility is that felony charges with the possibility of incarceration may have provided the wake-up
call needed for veterans to become motivated to address
mental health issues and engage in treatment. Veterans
who met VTC eligibility requirements received a second
chance—access to treatment, no drug or alcohol use, and
the opportunity to seal their records if they successfully
completed the intensive requirements of the program.
Another possible reason for VTC success may be that
participation restored access to peers–-at court, in treatment, and in the community in the form of peer mentors. For some veterans, the sudden loss of military structure, stability, and support may have impacted their overall
health and everyday coping skills. Restoration of access
to their peers, linkage to VA services, and opportunities to
file for changes in discharge status and disability benefits
may have contributed to participant success. The role of
peer mentors in veteran success is believed to be significant but requires further study.
Significant reduction on the Self-Harm Subscale of
the BASIS-24 suggests that suicidality declines with
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VETERAN TREATMENT COURTS CATCH, TREAT, AND RELEASE
participation in a VTC. Again, the team approach of the
VTC has helped provide many insights into the challenges
and needs of each individual and to develop custom solutions for each. The relationship between PTSD, substance
use disorders, and suicide risk was not explored in this
study, but it is clear that all three improved significantly
in the first 6 months of VTC participation and that improvements were sustained to 1 year.
Families already stressed by justice involvement become more stressed when housing and employment are
unstable. The benefits achieved by VTC participation by 6
months did not include significant improvements in housing and employment. The requirements of VTC participation are intensive and may have made it difficult for participants to hold down a full time job. Justice involvement is
another possible obstacle to both employment and housing. VTCs that have employment and housing stability as
goals would benefit from policies that promote, support,
and partner with their communities to overcome such barriers for justice-involved veterans as they recover.
Successful VTCs must identify the fine line between
motivation and punishment in their compliance requirements and create standards that help and heal the most
people. Taking a broad view, mental health, physical
health, financial stability, and family stability are all important elements in the overall health of individuals and
their possible contributions as productive members of
society.
Comprehensive evaluations of problem solving courts
must become standard to track program activities, goals,
measures, methods, and outcomes. Understanding the elements of VTCs that heal veterans and those that need to
be tweaked to avoid harm is an ongoing process. VTCs are
unique, like the individuals and communities they serve,
and there is no one-size-fits-all. Depending on the level
of exposure to trauma, and other challenges, such as substance use and TBI, the requirements that will be achievable and simultaneously heal individuals are best defined
with good data from a process evaluation.
Veterans showed improvement in mental health, substance use, and social reintegration after 6 months, which
was sustained at 12 months. These findings are consistent
with the possibility that VTCs are having a broad and substantial impact in the lives of troubled veterans. Further
research is clearly needed to better understand these potentially important institutions, evaluate their long-term
impact, and guide their widespread use. Initial evidence
suggests that VTCs work and may save lives.
Declaration of Interest
The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of the
article. The contents are solely the responsibility of the
authors and do not necessarily represent the official views
of SAMHSA.
Funding support for the study was provided by the
Jail Diversion and Trauma Recovery—Priority to Veterans Grant awarded to the Colorado Department of Human
Services, Division of Behavioral Health from the Sub-
929
stance Abuse and Mental Health Services Administration,
Grant #SM58806.
RÉSUMÉ
La prise, le Plaisir et la Libération: L’Adresse de Cours
de justice de Traitement Chevronnée les Défis de
Retour à la maison
Après une décennie de guerre, il y a un grand besoin
pour le traitement et les alternatives à l’incarcération pour
les vétérans de justice-impliqué. Les membres de service militaires américains retournent du combat avec les
défis de santé mentale substantiels qui augmentent le potentiel pour l’engagement de justice. Les Tribunaux de
Traitement de vétéran commencent à travers la nation
pour rencontrer ce besoin pour la justice thérapeutique.
Ces problème qui résout des tribunaux fournit l’accès
au traitement et la motivation pour l’engagement. La
preuve préliminaire d’une évaluation de SAMHSASUBVENTIONNE suggère que l’amélioration significative dans l’usage de PTSD et substance soit juste peu
d’entre les issues positives que ces tribunaux peuvent
aider des vétérans atteignent.
RESUMEN
Agarre, Trate, y Liberación: Dirección de Tribunales de
Tratamiento Veterana los Desafı́os de Volver a Casa
Después de una década de guerra, hay una gran necesidad de tratamiento y alternativas al encarcelamiento para
veteranos complicados de justicia. Los miembros de servicio militares estadounidenses vuelven del combate con
desafı́os de salud mental sustanciales que aumentan el potencial para la participación de justicia. Los Tribunales de
Tratamiento Veteranos comienzan a través de la nación
a encontrar esta necesidad de la justicia terapéutica. Estos tribunales de solución de problema proporcionan
el acceso a tratamiento y motivación para el compromiso. Pruebas preliminares de una evaluación SAMHSAfinanciada sugieren que la mejora significativa de PTSD
y uso de sustancia sea sólo algunos de los resultados positivos que estos tribunales pueden ayudar a veteranos a
conseguir.
THE AUTHORS
Michelle Slattery is the Lead
Evaluator for the Jail Diversion
and Trauma Recovery–Priority
to Veterans Grant at the UCCS
Trauma, Health & Hazards
Center as well as the President
of Peak Research, LLC. She
has an MA degree in human
factors Psychology. Her research
interests include the evaluation
of problem solving courts
and public health initiatives,
secondary trauma, trauma and
personality type, and STEM education.
930
M. SLATTERY ET AL.
Subst Use Misuse Downloaded from informahealthcare.com by University of Colorado on 11/26/14
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Mallory Natasha Dugger
is the Professional Research
Assistant for the Jail Diversion
and Trauma Recovery–Priority
to Veterans Grant at the UCCS
Trauma, Health & Hazards
Center. She has a BA degree in
psychology and a BA degree in
sociology. Her current research
interests include trauma and
personality type.
Theodore A. Lamb is a Senior
Consultant with Peak Research,
LLC, and an Assistant Dean of
Curriculum & Assessment at
Naropa University in Boulder,
CO, USA. His PhD is in
sociology and he is a combat
veteran of Viet Nam. His
research focus is on developing
predictive models of surviving
trauma and understanding the
role of contemplative education
practices in healing and social
change.
Laura Williams is the Project
Director for the Jail Diversion
and Trauma Recovery Priority to Veterans Grant at
the Colorado Department of
Human Services, Division of
Behavioral Health. She has an
MA degree and an MBA and
is also a Licensed Professional
Counselor. Her research interests
include the nexus between early
childhood trauma, abuse, and
loss and adult functioning,
resiliencies and vulnerabilities.
GLOSSARY
OEF/OIF: Operation Enduring Freedom/Operation Iraqi
Freedom.
PTSD: Posttraumatic stress disorder is a mental health
condition that may develop after experiencing traumatic events.
Substance abuse: Excessive use of alcohol or drugs.
TBI: Traumatic brain injury is a temporary or permanent
injury to brain cells caused by a blow to the head or
penetration of the skull.
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