Alisha Desai, PhDa; Ryan Holliday, PhDa,b; Matthew Stimmel, PhDc; Lauren M. Borges, PhDa,b
Correspondence: Alisha Desai (alisha.desai@va.gov)
aRocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
bUniversity of Colorado Anschutz Medical Campus, AuroracUS Department of Veterans Affairs Veterans Justice Programs, Washington DC
Author disclosures
The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Ethics
This qualitative improvement program was exempt from institutional review board approval.
Background: Justice-involved veterans demonstrate greater mental health and psychosocial needs relative to justice-involved nonveterans and veterans without a criminal history. Veterans treatment courts (VTCs) serve as an alternative to incarceration for veterans whose criminogenic risk is believed to be related to mental health symptoms. Despite observed improvements in functioning and recidivism risk following successful VTC completion, little is known about factors that impede engagement with VTCs. This paper describes a trauma-informed training program that included psychoeducation, skills training, and consultation and was developed for court professionals to facilitate veteran engagement in VTCs.
Observations: Needs assessments and court observations informed program development. Based on identified needs, the training incorporated skills from dialectical behavior therapy, acceptance and commitment therapy, and motivational interviewing. Two VTCs in the Rocky Mountain region participated in the pilot trauma-informed training, each lasting about 90 to 120 minutes. Feedback from attendees indicated that the focus on skills training—specifically, managing intense emotions, addressing ambivalence, and approaching sanctions and rewards—was uniquely helpful. The function of posttraumatic stress disorder symptoms and structure of evidence-based treatments were identified as useful educational components.
Conclusions: Veterans Health Administration mental health professionals can serve an important role in facilitating effective practices for professionals working within VTCs. This pilot program provided preliminary support for skills-based training to bolster communication, motivation, distress tolerance, and engagement among veterans court participants. Future directions of this program may include expanding the training into a full-day workshop, conducting comprehensive needs assessments, and examining program outcomes.
Veterans who interact with the criminal justice system (ie, justice-involved veterans) have heightened rates of mental health and psychosocial needs, including posttraumatic stress disorder (PTSD), substance use disorder, depression, suicidal ideation and attempt, and homelessness.1,2 Alongside these criminogenic risk factors, recidivism is common among justice-involved veterans: About 70% of incarcerated veterans disclosed at least one prior incarceration.3
To address the complex interplay of psychosocial factors, mental health concerns, and justice involvement among veterans, veterans treatment courts (VTCs) emerged as an alternative to incarceration.4 VTC participation often consists of integrated treatment and rehabilitative services (eg, vocational training, health care), ongoing monitoring for substance use, graduated responses to address treatment adherence, and ongoing communication with the judge and legal counsel.4
A primary aim of these courts is to address psychosocial needs believed to underlie criminal behavior, thus reducing risk of recidivism and promoting successful recovery and community integration for eligible veterans. To do so, VTCs collaborate with community-based and/or US Department of Veterans Affairs services, such as the Veterans Justice Outreach program (VJO). VJO specialists identify and refer justice-involved veterans to Veterans Health Administration (VHA) and community care and serve as a liaison between VTC staff and VHA health care professionals (HCPs).5
VTC outcome studies highlight the importance of not only diverting veterans to problem-solving courts, but also ensuring their optimal participation. Successful graduates of VTC programs demonstrate significant improvements in mental health symptoms, life satisfaction, and social support, as well as lower rates of law enforcement interactions.6,7 However, less is known about supporting those veterans who have difficulty engaging in VTCs and either discontinue participation or require lengthier periods of participation to meet court graduation requirements.8 One possibility to improve engagement among these veterans is to enhance court practices to best meet their needs.
In addition to delivering treatment, VHA mental health professionals may serve a critical interdisciplinary role by lending expertise to support VTC practices. For example, equipping court professionals with clinical knowledge and skills related to motivation may strengthen the staff’s interactions with participants, enabling them to address barriers as they arise and to facilitate veterans’ treatment adherence. Additionally, responsiveness to the impact of trauma exposure, which is common among this population, may prove important as related symptoms can affect veterans’ engagement, receptivity, and behavior in court settings. Indeed, prior examinations of justice-involved veterans have found trauma exposure rates ranging from 60% to 90% and PTSD rates ranging from 27% to 40%.1,2 Notably, involvement with the justice system (eg, incarceration) may itself further increase risk of trauma exposure (eg, experiencing a physical or sexual assault in prison) or exacerbate existing PTSD.9 Nonetheless, whereas many drug courts and domestic violence courts have been established, problem-solving courts with a specialized focus on trauma exposure remain rare, suggesting a potential gap in court training.
VHA HCPs have the potential to facilitate justice-involved veterans’ successful court and treatment participation by coordinating with VJO specialists to provide training and consultation to the courts. Supporting efforts to effectively and responsively address criminogenic risk (eg, mental health) in VTC settings may in turn reduce the likelihood of recidivism.10 Given the elevated rates of trauma exposure among justice-involved veterans and the relative lack of trauma-focused VTCs, we developed a trauma-informed training for VTC professionals that centered on related clinical presentations of justice-involved veterans and frequently occurring challenges in the context of court participation.
Veterans with a history of homelessness and justice involvement are at greater risk for mental health sequelae, including suicide; however, the VA...
