Introduction

Throughout the past century, the United States has been almost continuously involved in war. War veterans return to the country often with a sense of pride, but also with a variety of traumatic experiences that may lead to negative health consequences. Many develop unique behavioral and physical needs related to their service.[1] Some have difficulties readjusting after returning home from combat and may develop post-traumatic stress disorder (PTSD), depression, and substance use disorders (SUDs). Many also must adjust to physical injuries they received while serving, such as traumatic brain injuries (TBIs) and amputations.

Generally, the term veteran refers to a person who has completed service as a member of the armed forces.[2] While the term has various colloquial definitions, Title 38 of the U.S. Code defines a veteran as “a person who served in the active military, naval, or air service, and who was discharged or released therefrom under conditions other than dishonorable.”[3] This definition is important for deciding who receives veteran benefits, such as disability compensation, education, and employment services. Those who have been discharged on conditions considered other-than-honorable may not qualify for benefits under the law, compounding the difficulties of readjusting to civilian life. In addition, limited access to treatment and pervasive stigma against help-seeking can create barriers for veterans seeking services.[4]

For some, military experiences and difficulties adjusting to life after combat can contribute to criminal justice involvement. However, veterans’ experiences vary greatly—many never experience combat, develop physical or behavioral health problems, or encounter the justice system. Nonetheless, a disproportionate number of veterans find themselves involved in the criminal justice system, particularly for violent offenses.[5] This article explores the literature on issues that that may contribute to veterans’ justice system involvement. In addition, the authors describe programs and services designed to assist veterans.

Demographics of Veterans

Gulf War veterans make up the majority of today’s veteran population.[6] In 2017, 18 million veterans were living in the United States, including an estimated 628,254 residing in Illinois.[7] Projections indicate a decrease in the number of veterans to 14.5 million in coming decades due to diminished interest in joining the military and more intense qualification criteria (Figure 1).[8] Figure 2 depicts veteran demographic information by gender and race.[9]

Figure 1

Number of U.S. Veterans in Millions, 2015-2035

Number of U.S. Veterans in Millions, 2015-2013
Source: National Center for Veterans Analysis and Statistics (2019)

Figure 2

U.S. Veterans by Gender and Race, 2017

U.S. Veterans by Gender and Race, 2017
Source: U.S. Department of Veterans Affairs (VA), National Center for Veterans Analysis and Statistics
Note: Demographic labels were maintained from original data source

Women veterans

The number of women veterans has steadily increased, rising from 4 percent in 1990 to 9 percent in 2017, and it is expected to climb.[10] Women veterans report facing the same hardships as men upon returning to civilian life, ranging from physical ailments to mental health disorders (MHD) and SUDs. In addition, some women may be expected to act differently after enlistment. While military culture emphasizes detachment and toughness,[11] women veterans may be expected to be soft and nurturing caregivers once home, leading to a difficult transition.[12] In one survey of women veterans, 60 percent of respondents reported their military service had a negative impact on their physical and mental health.[13] Research is limited on justice-involved women veterans and little is known about their rehabilitative needs.

Homeless veterans

The U.S. Department of Housing and Urban Development estimates that 37,878 U.S. veterans are homeless on any given night, with more than 800 in Illinois alone.[14] Eighty percent of homeless veterans suffer from MHDs and/or SUDs.[15] Tsai and Rosenheck (2015) examined seven studies on factors contributing to veteran homelessness and concluded both substance misuse and poor mental health put these individuals at risk.[16] In a different study, veterans with a SUD had a five times greater risk of homelessness than those who did not have a SUD.[17] Another report found that one half of veterans who participated in a U.S. Department of Veterans Affairs (VA) homeless assistance program also were involved in the criminal justice system.[18]

Veterans in the Criminal Justice System

Criminal justice data on veterans is limited, as military status is not noted at arrest or other points in the system. In 2012, veterans comprised 8 percent of the incarcerated population.[19] Most justice-involved veterans were White men, although Black and Hispanic men were over-represented among incarcerated veterans in comparison to the total veteran population (Figure 3).[20] In 2018, 2 percent of Illinois Department of Corrections (IDOC) admissions self-identified as a veteran.[21]

Figure 3

Justice-Involved Veterans by Gender and Race, 2012

Justice-Involved Veterans by Gender and Race, 2012
Source: Bureau of Justice Statistics
Note: Demographic labels were maintained from original data source

A Bureau of Justice Statistics report on veteran incarceration indicated that around 64 percent of veterans were serving time for violent offenses, while 52 percent of non-veterans were serving time for the same offenses (Figure 4).[22] In addition, more incarcerated veterans were serving time for a violent sexual offense than non-veterans, at 35 percent and 23 percent, respectively.

Figure 4

U.S. Male Prisoners’ Most Serious Offense, 2012

U.S. Male Prisoners' Most Serious Offense, 2012
Source: Bureau of Justice Statistics
Note: Percentages do not equal 100 percent due to rounding

The prevalence of violent crime among veterans may be due to multiple factors. Veteran combat training may encourage aggression, readiness to fight, and other skills needed for quick decision-making in dangerous situations.[23] Elevated anger and hostility are symptoms of PTSD and TBI, which are commonly suffered by veterans.[24] In one study, 67 percent of Iraq and Afghanistan War veteran respondents reported threatening someone or exhibiting aggressive behavior in the past month.[25]

Aggression also has been related to higher rates of domestic violence among veterans. Combat veterans who have been diagnosed with PTSD may be at a higher risk of committing domestic violence.[26] Women veterans may be at a higher risk of domestic violence victimization; in one study, around 29 percent of women veteran respondents reported experiencing domestic violence within the last year, and almost half of those women experienced multiples types of violence.[27]

Veteran Needs that Contribute to Justice Involvement

Many veterans have witnessed traumatic events, including the deaths of civilians and fellow soldiers. This trauma may lead to physical and mental health symptoms that contribute to periods of homelessness and misuse of drugs and alcohol. It can also be challenging for veterans’ families to care for veterans with many needs—some caregivers may suffer from social isolation, emotional strain, and depression—which can further threaten veterans’ ability to live at home.[28]

Physical Health of Veterans

Chronic pain

In a national study of almost 68,000 adults, more veterans (66 percent) than non-veterans (56 percent) reported enduring pain in the previous three months; veterans also reported severe pain at a higher rate (9 percent) than non-veterans (6 percent).[29] Chronic pain conditions often faced by veterans include back pain with or without sciatica (pain down the back of the legs), joint pain, migraines, neck pain, and jaw pains.[30] Chronic pain also is strongly associated with TBI and PTSD. Further, the pain may serve as a constant reminder of the traumatic event that caused the condition, triggering PTSD and complicating treatment.[31] In one study, 17 percent of injured veterans and just 3 percent of non-injured veterans met the criteria for PTSD.[32] Often those who suffer from chronic pain are treated with opioid medications, which can lead to dependence.[33]

Amputations

From 2001 to 2015, around 1,700 U.S. military personnel suffered trauma-related amputation due to combat in Afghanistan and Iraq.[34] Adjusting to life after an amputation is difficult; individuals must relearn how to perform basic functions, such as walking and writing. These immense challenges may influence higher rates of psychopathology among persons with amputation than those in the general population.[35] Again, pain may be treated with opioids and long-term use can lead to dependence.

Hearing loss and tinnitus

Loud noises correlated with gun fire, blast exposure, and aircraft can cause hearing difficulties or the loss of hearing for veterans.[36] In 2017, 1.2 million veterans received disability compensation for hearing loss; 1.8 million received disability for tinnitus, a ringing in the ears.[37] Veterans who have hearing loss or tinnitus struggle to process speech in group situations or in spaces with background noise.[38] There is no cure for tinnitus, so veterans must learn to live with constant ringing, which may cause depression and anxiety.[39]

Traumatic brain injury (TBI) is defined as a disruption in the normal function of the brain caused by a bump, blow, or jolt to the head, or penetrating head injury. A mild TBI is sometimes referred to as a concussion. For military personnel, this can occur from blasts and injuries sustained during training and combat. TBI symptoms, such as changes in sleep patterns, can lead to long-term mental and physical health problems.

Source: Centers for Disease Control and Prevention, U.S. Department of Veteran’s Affairs

Traumatic brain injury

Side effects of TBI resulting from physical injury include chronic problems in thinking, memory, sensation, language, and emotion.[40] Severe TBIs often elicit uncontrolled feelings of anger, impulsivity, aggression, and violence.[41] As many as 20 percent of veterans who served in Iraq and Afghanistan returned home with a TBI.[42] Hoge and colleagues conducted a study of over 2,500 U.S. Army soldiers 3 to 4 months after returning home.[43] The study found 10 percent of the group reported TBIs, causing nightmares, triggering emotions, and increasing anxiety. Research indicates veterans often use alcohol or drugs to avoid emotional discomfort, which can lead to a SUD.[44]

Behavioral Health of Veterans

Post-traumatic stress disorder (PTSD)

Some tactics used to elicit fear in war, such as guerilla warfare, roadside improvised explosive devices (IEDs), and uncertain distinctions between safe zones and battle zones can lead to PTSD.[45] PTSD is characterized by unwanted, intrusive thoughts, avoidance of trauma-related cues, sustained anxiety, and hyperarousal.[46] Symptoms vary in severity but can include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts.[47] In a study of 60,000 veterans who served in Iraq and Afghanistan, 14 percent screened positive for PTSD.[48] Roughly 30 percent of Vietnam War veterans were diagnosed with PTSD while only about 8 percent of citizens within the general population suffer from the disorder.[49] Several studies have linked PTSD with anger, aggressiveness, substance use, and interpersonal violence.[50]

Stress and moral injury

Instead of, or in addition to, a diagnosable MHD, veterans may experience general stress, which can further impact their well-being. Stress is a feeling of physical and emotional tension experienced by many in the general population due to a myriad of events and thoughts. For veterans, stress may be brought on by difficulties in finding employment, conflicts with family and friends, and challenges readjusting to civilian life.[51]

In addition to stress, veterans may experience “moral injury,” which Mobbs and Bonanno define as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply moral beliefs and expectations.”[52] Veteran experiences during war can lead to feelings of guilt or shame that can impact a veteran’s well-being.[53]

Military sexual trauma (MST)

MST is not an actual diagnosis, but is defined as experiences of sexual assault or repeated, threatening acts of sexual harassment including psychological trauma while in training or on active duty.[54] In one study, 1 in 5 women veterans who visited a VA facility reported MST, compared to 1 in 100 men.[55] MST may go underreported due to fear of retaliation, not being believed, or feelings of helplessness.[56] MST is strongly corelated with diagnosable disorders of anxiety, depression, SUDs, personality disorders, and PTSD.[57]

Substance misuse

The self-medication hypothesis is one theory of addiction posed by Khantzian that suggests individuals use substances to cope with symptoms of illness.[58] One study of Vietnam veterans found that drugs, such as heroin, benzodiazepines, and marijuana, were commonly used to lessen PTSD symptoms.[59] According to the U.S. Bureau of Justice Statistics, 61 percent of veterans in state prison and 57 percent of veterans in federal prison met the criteria for a SUD.[60] Further, veterans with MHDs or injuries often are prescribed medications such as opioids, benzodiazepines, and sedatives, on which they can develop a tolerance and dependence.[61] Veterans with PTSD often are prescribed larger doses of opioids, increasing the likelihood of dependence.[62]

Military Culture and Stigma

Within the armed forces, the culture that defines how soldiers are expected to behave is referred to as the “warrior ethos.”[63] It emphasizes unit cohesion (i.e., putting collective needs over personal needs), devotion to the mission, and stoicism. Since personal needs are considered secondary, those who seek help may be viewed as weak or a security risk.[64] Unlike most civilian supervisory personnel, soldiers’ commanding officers have access to mental health records.[65] Those seen as mentally or physically unfit are subject to service discharge. This may lead to a reluctance to seek help for mental health issues. In one study, 23 to 40 percent of Operation Enduring Freedom and Operation Iraqi Freedom veterans reported seeking mental health care and almost 50 percent indicated an interest in seeking mental health care.[66] Even when veterans are no longer on active duty, a military culture that discourages help-seeking may persist after service.[67]

Addressing the Needs of Veterans

The National Institute of Corrections, along with the Substance Abuse and Mental Health Services Administration (SAMHSA) and the VA, developed a sequential intercept model to divert veterans at various points of the criminal justice system. The first intercept is with law enforcement or emergency responders trained in suicide prevention, PTSD identification and response, and handling co-occurring MHDs and SUDs.[68] The next intercepts are at initial detention and court hearings, followed by jails and courts, and then finally at community services, which offer different programming and strategies meant to aid justice-involved veterans.

The U.S. Department of Veterans Affairs (VA) offers a wide range of benefits and services for veterans of the U.S. Armed Forces. The VA is comprised of three main units: the Veterans Benefits Administration, the Veterans Health Administration, and the National Cemetery Administration. In Illinois, the VA operates five inpatient care sites, 30 outpatient care sites, and 11 veteran centers.

Source: U.S. Department of Veteran’s Affairs, National Center for Veterans Analysis and Statistics

Criminal Justice System Diversion Programs

Veterans Treatment Courts

The Illinois Veterans and Servicemembers Court Treatment Act [730 ILCS 167] recognizes veterans suffer many negative side effects after experiencing military service and combat and requires the criminal justice system to both protect the general public and rehabilitate qualifying veterans.[69] In response, Veterans Treatment Courts (VTCs), a problem-solving court model, offer treatment designed specifically for the veteran population. These courts allow veterans to focus on rehabilitation and avoid criminal conviction. The court combines mandatory attendance at treatment sessions, court appearances, and frequent and random drug and alcohol testing.[70]

In 2018, there were more than 400 VTCs in the United States, including 18 VTCs operating in 12 Illinois counties.[71] Participation in a VTC requires an agreement between the court, prosecutor, and defendant.[72] Individuals must be willing to participate and may be excluded from participation depending on the severity of the crime committed.[73] Court program participants must plead guilty to charges, sign a treatment contract, report to a probation officer and VA case manager as required, submit to random drug tests, avoid illegal substances and criminal behaviors, possess no weapons, complete community service, and attend self-help programs.[74]

VTC judges take into consideration military service-related factors that may have contributed to the veteran’s offending, such as symptoms of a SUD, PTSD, TBI, or MTS. This allows the judge to find a route through the system that is specific to their needs. During the court docket, a veterans’ specialist provides the veterans’ medical history and treatment plan options to the court. The state VA also offers local and state resources. These resources are key factors in rehabilitating veterans who find themselves involved with the criminal justice system.

Veteran mentors

Often veterans themselves, veteran mentors provide treatment court participants with moral support and guidance.[75] Mentors also assist with housing, employment, transportation, disability compensation claims, and contesting discharge status.[76] With an understanding of military culture, VTC mentors can provide a more empathic understanding of what justice-involved veterans are experiencing and are aware of the importance of team support.[77] Overall, mentors play a huge role in veterans’ success and the relationship between a participant and their mentor can extend beyond justice involvement.[78]

Effectiveness of VTCs

Tsai and colleagues conducted a study in which they examined data on 7,931 VTC participants between 2011-2015.[79] On average, veterans spent 11 months in the program. Twenty percent of VTC participants received jail sanctions while in the program, and 14 percent experienced a new period of incarceration within one year. In contrast, the average one-year recidivism rate of all U.S. prisoners is between 23 and 46 percent.[80] The study also revealed an increase in the number of veterans who received and accessed VA benefits, jumping from 38 percent to 50 percent by the time the participants exited the program.[81] In another study, an impact evaluation on a large urban VTC found that VTC participants had lower recidivism and re-arrest rates than non-participants.[82]

While some VTCs have received support among participants,[83] ongoing data collection and outcome evaluation is needed to determine their overall effectiveness at diverting offenders and reducing recidivism. VTCs were adopted rapidly and, in many cases, before standardized best practices and strategies were identified.[84] Additionally, veteran mentors, who are considered integral members of VTCs, are sometimes provided little training on their role and little guidance on how to intervene in risky situations.[85] Future research could identify best practices and characteristics of veterans who benefit most from the program.

Veteran Justice Outreach Program

The U.S. VA created the Veteran Justice Outreach program (VJO), which has the primary function of helping veterans avoid unnecessary jail or prison time and ensuring that veterans have access to U.S. Veterans Health Administration (VHA) services. VJO’s goal is to successfully rehabilitate veterans through court-approved treatment programs that allow alternatives to incarceration.[86] VJO works to create partnerships with law enforcement agencies, jails, and courts to properly treat offending veterans rather than incarcerate them. They also ensure that veterans have access to all VA resources for which they are eligible, such as health care, mental health, and substance use services. Although the VA is not allowed to provide legal assistance, they make sure that veterans are informed about alternatives to incarceration, such as VTCs.[87]

Correctional Programs

Veterans Moving Forward

Veterans Moving Forward (VMF) is a male, veteran-only program and housing unit in jails and prisons across the country.[88] In these units, veterans live and operate in a military-like, structured environment and obtain services, such as counseling. Excluded from participation are veterans in maximum security prison, sex offenders, those in medical segregation, those with less than 30 days to serve, and those with disciplinary infractions or prior psychiatric holds.[89] The main goal of VMF is to provide a structured environment that incorporates positive aspects of military culture and camaraderie to create a safe space for healing and rehabilitation.[90] VMF combines cognitive therapy with a curriculum that includes meditation and critical thinking. This program assists veterans with self-awareness, problem-solving skills, and self-control.

In one survey, 98 percent of treatment group participants said that they would recommend VMF to another veteran, with many stating they obtained resources they would not have otherwise received.[91] In a six-month follow-up survey of the same group, 94 percent reported their needs related to critical thinking had been met and 88 percent reported their needs related to general reintegration had been met.[92] Veterans within the VMF program in San Diego, Calif., were also less likely to reoffend than those who did not participate in the program.[93]

Conclusion and Recommendations for Policy and Practice

Many military veterans return to civilian life without complications; however, for some, physical and mental health issues along with stigma attached to help-seeking can lead to justice involvement. Transitioning out of the structured environment of the military can be challenging and is often exacerbated by a lack of support from both peers and institutions.[94] Those who do seek treatment often face barriers, such as a lack of service availability or lack of available veteran-centered services.[95] An increasing number of services are being made available to veterans in the criminal justice system. Veteran service provision can be bolstered with the followin recommendations.

Offer Services to Justice-Involved Veterans

The criminal justice system should continue to implement services that consider the unique needs of veterans. Over half of justice-involved veterans have at least one mental health concern,[96] and many have SUDs.[97] Early screening for these conditions is vital.

Demographic considerations also should be made when developing veteran treatment programs. Veteran-focused services, such as VTCs, may be important for increasing veteran engagement in treatment, as those who have served in the armed forces may feel most comfortable working with those who understand military culture.[98] On the other hand, some veterans may feel more stigmatized by other members of the military, so it is important to consider a veteran’s preference before assigning treatment.[99]

Combat the Stigma of Help-Seeking

Addressing behavioral health issues may reduce risk for criminal justice involvement. Therefore, reducing the stigma attached to help-seeking in the military should remain an area of focus. Educational briefings for current military members and veterans could offer an overview of physical and behavioral health symptoms, provide examples of treatment success, emphasize the potential negative outcomes absent treatment, and increase interest in help-seeking.[100] Putting a face to veterans who have received services and who can explain how those services improved their lives can make positive outcomes seem more realistic. The VA’s Make the Connection website features videos and stories about other veterans and their recovery experiences. The website also provides resources based upon location. While this may be a helpful service, researchers should evaluate the level of awareness of this campaign and its effectiveness.

Motivational interviewing (MI) may improve interest and readiness for treatment among those who are uninterested in seeking help. MI is a time- and cost-efficient counseling method that is targeted to those who may be ambivalent or resistant to change, so it may work well in veteran populations that report high levels of stigma. The strategy employs a client-centered style of counseling that, rather than focusing on what a person should and should not do, explores the individual’s various thoughts and feelings related to treatment and assesses their values and motivations.[101] One study found that MI significantly increased Iraq and Afghanistan veterans’ interest in and retention of mental health treatment.[102] Another study found that MI delivered in a group setting was effective in enhancing treatment engagement for homeless veterans with a SUD.[103]

Conduct Additional Research

Understanding the reasons why veterans offend and how their motivations differ from those of the general population can lead to enhanced treatment outcomes. Research is needed on justice-involved veterans. Demographic research would be especially helpful to address needs of veterans who are people of color, women, or who live in rural areas.[104] Future research on VTCs must identify which program components are most effective and standardize the use of validated risk assessment tools.[105] Learning what works for veterans may also provide treatment benefits for non-veteran, justice-involved individuals that have experienced similar physical and behavioral traumas.[106]

Veterans in crisis can call 1-800-273-8255 and press 1, chat online, or text 838255 for help.

The authors would like to thank Jeff Ross and Frank Morelli from Lake County Adult Probation for their contributions to this article.

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