Over the last 5 years, Veterans Treatment Courts have been established across the country to address the unique challenges posed by our nation’s veterans who suffer from addiction, psychiatric illness, and/or co-occurring disorders, and who also run afoul of the law.
One study of almost 250,000 veterans who had returned from Iraq and Afghanistan and were under Veterans Affairs care found that 35% of them had received mental health diagnoses, including adjustment disorder, depression, and substance use disorders. The most prevalent mental health diagnosis was posttraumatic stress disorder (J. Gen. Intern. Med. 2010;25:18-24).
Meanwhile, a Bureau of Justice Statistics Special Report found that 9.3% of people incarcerated in jails are veterans and the majority of those serving time were for nonviolent crimes. More than 29% of the violent offenses among offenders who were in military correctional facilities came under the categories of rape and "other sexual assault." The report estimates that at least 90,000 of the 9 million inmates annually released from U.S. jails are veterans and that 82% are eligible for VA services.
Reintegrating into civilian life can be profoundly challenging for veterans, particularly when they also suffer from psychiatric illness, substance use disorders, and/or traumatic brain injury. Veterans often return to a life lacking in adequate support, which may result in unemployment, limited social connectedness, and housing problems. The physical and emotional scars that many veterans acquire during active duty also can be the catalyst for progressive mental health decline. Returning service members are at increased risk of engaging in unsafe risk-taking behaviors, such as reckless driving and heavy drinking (Drug Court Rev. 2011;3:171-208). Furthermore, many veterans live in rural areas with limited access to mental health care. To make matters worse, there continues to be a stigma among veterans that is associated with mental health treatment. Veterans Treatment Courts (VTCs) help to divert veteran defendants into community-based treatments where they are offered access to a comprehensive package of medical and mental health resources through the VA, as well as peer support services.
VTCs grew out of the drug court movement. The first VTC was formed in Buffalo, N.Y., in 2008 by Judge Robert Russell, who grew frustrated with the number of nonviolent veteran offenders forced to enter the criminal justice system after being arrested for crimes related to substance and mental health problems. Opponents of VTCs argue that all citizens, regardless of veteran status, should be afforded equal protection under the law and treated the same. However, while there have been no elegant outcome studies done thus far, state reports indicate that VTCs save taxpayers money and contribute to lower rates of recidivism.
Because of the many complexities of treating veterans, clinicians should embrace a culture of recovery. In particular, contingency management and the use of positive-reinforcement systems should be a standard and central practice in all treatment settings. Servicemen and -women have experienced trauma in order to protect our freedoms and ensure our safety, and it is our collective job to support a compassionate system that makes every effort to help our veterans avoid incarceration, which can be a retraumatizing experience. Many patients who are eligible for VA services are not connected to those services and clinicians should make appropriate referrals if necessary.
Dr. Ascher is a postdoctoral fellow at the Philadelphia VA Medical Center and clinical instructor in psychiatry at the University of Pennsylvania, Philadelphia.