Justice Involved Veterans Lab
Treatments for Justice-Involved Veterans Lab:
Recent Publications
2025
Prevalence of mental health conditions, substance use disorders, suicidal ideation and attempts, and experiences of homelessness among Veterans with criminal-legal involvement: A meta-analysis
Veterans with histories of criminal-legal system involvement are considered high-priority within Veterans Health Administration (VHA) and criminal-legal settings. Over several decades, a large literature has accumulated to study these Veterans’ needs. To consolidate findings, this meta-analysis provides aggregated prevalence estimates of common mental health conditions, substance use disorders, suicidal thoughts and behaviors, and experiences of homelessness among Veterans with current or prior involvement with the United States criminal-legal system. A total of 79 samples encompassing over 1.2 million Veterans were analyzed. Results estimate 8 in 10 Veterans with criminal-legal involvement experience a mental health condition, 7 in 10 a substance use disorder, 1 in 10 a history of suicidal ideation, and 4 in 10 a history of homelessness. Veterans with current (versus prior) criminal-legal involvement had higher rates of alcohol use, drug use, and current homelessness. Samples consisting of Veterans with a history of incarceration and samples collected in non-VHA settings tended to have lower rates of psychosocial difficulty relative to samples consisting of Veterans with other forms of criminal-legal involvement or collected in VHA settings, respectively. Remaining gaps in the literature include research on criminal-legal involved Veterans under community supervision, and/or from demographic minority groups.
Authors: Emily R. Edwards, PhD; Anthony Fortuna, MS; Ryan Holliday, PhD; Helena Addison, PhD, RN; Jack Tsai, PhD
https://doi.org/10.1016/j.cpr.2024.102533
Psychosocial needs of incarcerated veterans with other than honorable discharge characterizations.
The Veterans Health Administration recently expanded eligibility to allow behavioral health care for veterans with “other than honorable” (OTH) discharge characterizations, a group with unique demographic and psychosocial needs, including overrepresentation in criminal-legal contexts. To guide the integration of these veterans into Veterans Health Administration behavioral health care settings, this study offers initial insight into the needs of veterans with OTH involved in the criminal-legal system. Using data from the 2016 Survey of Prison Inmates, analyses compared incarcerated veterans with OTH (n = 179) to those with honorable or general discharge characterizations (n = 1,335) on demographic profile, criminal-legal history, and psychosocial factors. Veterans with OTH were more often younger, persons of color, incarcerated for drug-related offenses, diagnosed with psychotic and personality disorders, experiencing housing and occupational instability immediately preceding arrest, and with a history of substance use treatment. Results highlight the need for culturally sensitive approaches capable of addressing complex difficulties commonly faced by this population.
Authors: Emily R. Edwards, PhD: Sharon Alter, MA; Ryan Holliday, PhD: Anthony Fortuna, MS; Matthew Stimmel, PhD
https://doi.org/10.1037/ser0000956
2024
Understanding Criminogenic Risk Factors Among United States Military Veterans: An Updated Literature Review
Justice-involved veterans (JIVs) are a high-priority subgroup within the U.S. judicial system. In recent years, empirical research into the characteristics, needs, and outcomes of this veteran subgroup has developed rapidly. To allow research to better inform efforts to support JIVs, a systematic review was completed to organize existing literature on criminogenic risk within this population through the lens of the Risk-Need-Responsivity Model. Of the eight risk factors theorized by the Risk-Need-Responsivity Model, history of antisocial behavior and substance use had the most robust evidence as criminogenic risk factors for veteran justice involvement. Modest evidence was identified for antisocial personality, educational and occupational difficulties, and disruptions to family and marital relationships as risk factors. However, only limited evidence was identified for antisocial thinking, affiliation with antisocial peers, and lack of prosocial activities as risk factors due to these factors being relatively underassessed in research. Such patterns provide insight into potential interventions and supports for JIVs while also highlighting areas for continued research.
Authors: Emily R. Edwards, PhD; Gabriella Epshteyn, MA; Brigid Connelly; Clare Redden; Christelle El Hage Moussa; Daniel M. Blonigen, PhD; Matthew Stimmel, PhD; Ryan Holliday, PhD; and Terra Osterberg, MA
https://doi.org/10.1177/07340168231160862
Impact of Expanded Eligibility for Veterans With Other Than Honorable Discharges on Treatment Courts and VA Mental Health Care
Background: US Department of Veterans Affairs (VA) eligibility policies now allow comprehensive mental and behavioral health care services to be provided to veterans who received an Other than Honorable (OTH) discharge upon separation from service. Research has shown a disproportionate mental health burden and elevated rates of criminal-legal involvement among these veterans. Eligibility policy shifts may impact programs and services designed to support veterans with criminal-legal involvement, such as veterans treatment courts. Observations: Professionals serving veterans with criminal-legal involvement should become familiar with changes to VA eligibility policies and to allow these changes to inform revisiting strategies, policies, and procedures surrounding the engagement and enrollment of veterans with OTH discharge characterizations. Veterans with OTH discharges often experience disproportionate mental health burdens and are overrepresented in judicial and correctional systems. Conclusions: Professionals within judicial and correctional systems, particularly veterans treatment court programs, are encouraged to familiarize themselves with changes to VA eligibility policies and to revisit strategies, policies, and procedures surrounding the engagement and enrollment of veterans with OTH discharge characterizations into justice-focused programming and services.
Authors: Emily R. Edwards, PhD; Anthony Fortuna, MA; Matthew Stimmel, PhD; Daniel Gorman, LCSW; Gabriella Epshteyn, MA
https://doi.org/10.12788/fp.0511
Lower rates of VA service use among Native Hawaiian and Pacific Islander Veterans with criminal-legal involvement.
Veterans with criminal-legal involvement (VCLIs) experience high rates of negative health sequelae, including psychiatric conditions. The Department of Veterans Affairs (VA) offers programs tailored to VCLIs that emphasize identification of health conditions and connection to services. Unfortunately, contextual factors associated with criminal-legal involvement (e.g., financial and transportation difficulties) can impede engaging in VA services. These contextual factors may disproportionately affect Native Hawaiian and Pacific Islander (NHPI) Veterans. Analyses compared NHPI VCLI and non-NHPI VCLIs on VA service use. Results reflected lower rates of general and mental health VA service use among NHPI VCLI as compared to non-NHPI VCLI after adjusting for age and sex. Results highlight potential disparities in VA service use among VCLIs, with NHPI VCLIs using fewer VA services than both non-NHPI and White VCLIs.
Authors: Ryan Holliday, PhD; Nicholas Holder, PhD; Emily R. Edwards, PhD; Sara Wong, PhD; Shiloh E. Jordan, PhD; Katharine Stewart, PhD; Matthew Stimmel, PhD; Lindsey L. Monteith, PhD
https://doi.org/10.1016/j.genhosppsych.2024.04.005
2023
Dialectical Behavior Therapy for Justice-Involved Veterans (DBT-J): Feasibility and Acceptability
Justice-involved veterans are a high-risk, high-need subgroup serviced by behavioral health services within the Veterans Health Administration (VHA) system. Justice-involved veterans often have complex mental health and substance use difficulties, a myriad of case management needs, and a range of criminogenic needs that are difficult to treat with traditional outpatient VHA services. The present study represents an initial evaluation of dialectical behavior therapy for justice-involved veterans (DBT-J), a novel psychotherapy program providing 16 weeks of skills-based group therapy and individualized case management services to veterans with current or recent involvement with the criminal justice system. A total of 13 veterans were successfully enrolled into this initial acceptability and feasibility trial. Results broadly suggested DBT-J to be characterized by high ease of implementation, successful recruitment efforts, strong participant attendance and retention, high treatment fidelity, and high acceptability by veteran participants, DBT-J providers, and adjunctive care providers alike. Although continued research using comparison conditions is necessary, veterans who completed participation in DBT-J tended to show reductions in criminogenic risk across the course of treatment. Cumulatively, these findings suggest DBT-J holds potential as a VHA-based intervention to address the various needs of justice-involved veterans.
Authors: Emily R. Edwards, PhD; Ariana Dichiara, PsyD; Gabriella Epshteyn, MA; Shayne Snyder, MA; Shoshana Linzer, MS; Kristen Riglietti, MA; Nicole Weishoff, MS; Alice Lee, MA; Jack Tsai, PhD; Eddie Marcano, LCSW; Joseph Geraci, PhD; Marianne Goodman, MD
https://doi.org/10.1037/ser0000691
Dialectical Behavior Therapy for Justice-Involved Veterans: Changes in Treatment Targets in a Small, Pre–Post Design Clinical Trial
Dialectical Behavior Therapy for Justice-Involved Veterans (DBT-J; Edwards, Dichiara, Epshteyn, et al.,2022) was recently developed as an integrative psychotherapy + case management intervention to address the range of complex criminogenic, mental health, substance use, and case management needs commonly faced by justice-involved veterans. Research to date suggests delivery of DBT-J to be both acceptable and feasible (Edwards, Dichiara, Epshteyn, et al., 2022). However, data on therapeutic change experienced by DBT-J participants has been limited. The present study represents an initial investigation into longitudinal changes in criminogenic risk, psychological distress, substance use, case management needs, and quality of life experienced by 20 justice-involved veterans across their course of DBT-J participation. Results reflected notable improvements across treatment targets from pre- to posttreatment; these gains were largely maintained at 1-month follow-up. Such findings attest to the potential utility of DBT-J and to the need for continued research into the efficacy of this intervention.
Authors: Emily R. Edwards, PhD; Gabriella Epshteyn, MA; Shayne Snyder, MA; Daniel Gorman, LCSW; Brettland Coolidge; Eddie Marcano, LCSW; Jack Tsai, PhD; Marianne Goodman, MD
https://doi.org/10.1037/ser0000766
Personality Disorder Diagnosis Among Justice-Involved Veterans An Investigation of VA Using Veterans
Justice-involved veterans are more likely to experience myriad mental health sequelae. Nonetheless, examination of personality psychopathology among justice-involved veterans remains limited, with studies focused on males within correctional settings. We examined Department of Veterans Affairs (VA) electronic medical records for 1,534,108 (12.28% justice-involved) male and 127,230 (8.79% justice-involved) female veterans. Male and female veterans accessing VA justice-related services were both approximately three times more likely to have a personality disorder diagnosis relative to those with no history of using justice-related services. This effect persisted after accounting for VA use (both overall and mental health), age, race, and ethnicity. Augmenting and tailoring VA justice-related services to facilitate access to evidence-based psychotherapy for personality psychopathology may promote optimal recovery and rehabilitation among these veterans.
Authors: Ryan Holliday, PhD; Alisha Desai, PhD; Emily R. Edwards, PhD; Lauren M. Borges, PhD
http://doi.org/10.1097/NMD.0000000000001627
Understanding changes in aggression among U.S. army soldiers: The role of trauma exposure during deployment
Aggression is one of the leading concerns reported by United States service members and veterans. Trauma and posttraumatic stress disorder (PTSD) symptoms have emerged as key drivers of aggression. Research to date, however, has largely overlooked the effect of aggression on increasing risk of trauma exposure and subsequent PTSD. The current study addresses this gap by examining whether (a) pre-deployment aggression predicts trauma exposure on deployment and post-deployment PTSD, (b) trauma exposure on deployment and post-deployment PTSD predict post-deployment aggression, and (c) trauma exposure on deployment and post-deployment PTSD symptoms explain changes in aggressive behavior from pre-to post-deployment. Data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) Pre/Post Deployment Study (PPDS) on nationally representative sample of 8558 Active-duty Army soldiers were analyzed. Results revealed positive correlations between pre-deployment aggression (assessed via items from the Joint Mental Health Advisory Team 7), trauma exposure on deployment (assessed via items from the Deployment Stress Scale), post-deployment PTSD symptoms (assessed via items from the civilian PTSD Checklist and PTSD Checklist for DSM-5), and post-deployment aggression. Further, pre-deployment aggression predicted trauma exposure on deployment and post-deployment PTSD; trauma exposure on deployment and post-deployment PTSD predicted post-deployment aggression; and changes in aggression from pre-to post-deployment were partially mediated by trauma exposure on deployment and post-deployment PTSD symptoms. Collectively, these findings highlight the utility of identifying and addressing pre-deployment aggression in mitigating trauma exposure and later psychopathology.
Authors: Alison Krauss, PhD; Emily R. Edwards, PhD; Danny Ruiz, MA; Gabriella Epshteyn, MA; Brettland Coolidge; Marianne Goodman, MD
https://doi.org/10.1016/j.jpsychires.2023.06.015
2022
Understanding risk in younger Veterans: Risk and protective factors associated with suicide attempt, homelessness, and arrest in a nationally representative Veteran sample
Accumulating research suggests unique patterns of suicide risk, homelessness, and criminal-justice involvement in younger (age < 40) relative to older (aged 40+) cohorts of Veterans. However, potential explanations for these differences remain unclear. To address this gap, we analyzed data from a nationally representative sample of more than 4,000 US military Veterans to compare risk and protective correlations of prior suicidal behavior, homelessness, and justice-involvement in younger versus older Veterans. Results revealed that younger Veterans were significantly more likely than older Veterans to have a history of suicide attempt(s) (13.9% vs. 2.7%) and homelessness (22.5% vs. 8.7%). They also scored higher on measures of risk factors and lower on measures of protective factors. However, some factors – specifically, resilience, grit, impulsiveness, perceptions of the effect of the military on one’s life and social support – were less strongly associated with a history of adverse events in younger versus older Veterans. Findings highlight the need for preventative homelessness and mental health services for younger Veterans that are tailored to the unique characteristics and needs of this age cohort.
Authors: Emily R. Edwards, PhD; Ariana Dichiara, PsyD; Molly Gromatsky, PhD; Jack Tsai, PhD; Marianne Goodman, MD; Robert Pietrzak, PhD
https://doi.org/10.1080/08995605.2021.1982632
Arrest History and Psychopathology Among Veterans at Risk for Suicide
While preliminary evidence suggests an association between legal involvement and suicide risk among veterans, no research to date has explored the prevalence and/or correlates of legal involvement among veterans at high risk for suicide. The current study examined the relation of suicide attempt, suicidal ideation, and psychopathology to history of criminal arrest in a sample of 286 veterans at risk for suicide. Results indicated approximately half (47%) of at-risk veterans had a history of arrest. Inconsistent with hypotheses, arrest history was not associated with history of suicide attempt, current suicidal ideation, or severity of psychopathological symptoms. Arrest history was, however, associated with diagnoses of substance use disorder and antisocial personality disorder in this high-suicide risk sample. Further, likelihood of an antisocial personality disorder diagnosis was associated with higher frequency of past arrests. Taken together, results indicate that many veterans at risk for suicide have a history of arrest, and at-risk veterans with such history likely have a specific pattern of psychopathology, including antisocial personality traits and substance use. As such, legal status and history of justice involvement may be important considerations when assessing suicide risk and management of this high-risk population.
Authors: Emily R. Edwards, PhD; Molly Gromatsky, PhD; D. R. Gina Sissoko, MA; Erin A. Hazlett, PhD; Sarah R. Sullivan, MS; Joseph Geraci, PhD; Marianne Goodman, MD
http://dx.doi.org/10.1037/ser0000454
Mental Health of Incarcerated Veterans and Civilians: Latent Class Analysis of the 2016 Survey of Prison Inmates
Using data from the 2016 Survey of Prison Inmates, this study used latent class analysis to examine patterns of mental health comorbidity within a large, nationally-representative sample of incarcerated adults (N = 24,848), including 7.6% with prior military service. Classes were compared on Veteran status, military service-related variables, and treatment-related variables. Results suggest four latent mental health patterns—“Low Psychopathology” (70% of the total sample), “Internalizing + Thought Disorder” (8%), “Internalizing” (14%), and “High Psychopathology” (8%). The High Psychopathology class had the highest rates of prior psychiatric/psychological treatment. Incarcerated Veterans were more likely to be in the Internalizing class, and rates of combat exposure, military service-related injury, and less-than-honorable military discharge were highest in Internalizing and High Psychopathology classes. Results attest to the importance of person-centered mental health care within correctional settings and suggest a “treatment track” or “step-based” approach may best address the needs of individuals in these settings.
Authors: Emily R. Edwards, PhD: Ashley L. Greene, PhD; Gabriella Epshteyn, MA; Molly Gromatsky, PhD; Adam R. Kinney, PhD; Ryan Holliday, PhD
http://doi.org/10.1177/00938548221121142
Disentangling Associations Between Military Service, Race, and Incarceration in the U.S. Population
The current study examined (a) how veteran status, race, and other individual characteristics are associated with any lifetime incarceration in the U.S. adult population; and (b) differences between veterans and other adults with any incarceration histories on sociodemographic, health, and psychosocial characteristics. Data from structured interviews conducted in 2012–2013 on a nationally representative sample of 36,121 U.S. adults were analyzed. Results showed that male gender, U.S. born, history of homelessness, antisocial and borderline personality disorders, and various substance use disorders were independently associated with any lifetime incarceration (all adjusted odds ratios [AORs] ≥ 1.5). Veteran status was not significantly associated with any lifetime incarceration (AOR = 1.12). Among adults with any lifetime incarceration, veterans were more likely to be male than nonveterans (AOR = 5.90), but were otherwise similar in sociodemographic background, physical and mental health, and psychosocial characteristics. Being black was moderately associated with lifetime incarceration among both veterans and nonveterans (AOR = 1.54 and 1.50, respectively) with no significant veteran × race interaction. Collectively, these findings suggest veterans and nonveterans are similarly represented among Americans with any lifetime incarceration and share similar factors associated with incarceration. Although prevalence of incarceration did vary by race, psychosocial and substance abuse factors emerged as the major factors associated with incarceration, highlighting the importance of behavioral health and social services for at-risk adults across military and civilian settings.
Authors: Jack Tsai, PhD; Emily Edwards, PhD; Xing Cao, PhD; Andrea K. Finlay, PhD
https://doi.org/10.1037/ser0000537
Historical Trends in Veteran Community Substance Use Treatment: 2000–2019
Background: Substance use is a significant health crisis for the Veteran population. Prior research has thoroughly examined Veteran substance use within Veterans Health Administration (VHA) settings. However, such data tends to be outdated, and there is minimal research on substance use services delivered outside of VHA systems. This study examines historical patterns of Veteran substance use using a large sample of community-based substance-use treatment admissions. Methods: Data were drawn from the Substance Abuse and Mental Health Data Archive Treatment Episode Data Set-Admissions. Of the 39,425,886 total admissions between 2000 and 2019, 1,361,339 were of Veterans. Analyses compared Veteran versus non-Veteran admissions on demographics and historical trends in nature of substance-use admissions. Results: Relative to non-Veterans, Veteran admissions were more likely to be prompted by alcohol use. Over time, heterogeneity in substances prompting admissions has increased dramatically for both Veterans and non-Veterans, with particularly notable increases in opiate and stimulant use. Conclusion: Results suggest Veterans admitted to community substance-use treatment are unique relative to their non-Veteran peers. Development and implementation of treatments to target a range of substances while also considering the environmental challenges (e.g., homelessness) commonly faced by this population appear essential to best servicing community-based Veterans.
Authors: Emily R. Edwards, PhD; Gabriella Epshteyn, MA; Ariana Dichiara, PsyD; Shayne Snyder, MA; Daniel Gorman, LCSW
https://doi.org/10.1080/10826084.2022.2096235
2021
Mental Health and Substance Use Patterns Associated With Lifetime Suicide Attempt, Incarceration, and Homelessness: A Latent Class Analysis of a Nationally Representative Sample of U.S. Veterans
A substantial proportion of U.S. military veterans experience mental health and/or substance use disorders. As public awareness of these difficulties rises, so too does interest in the relation between veteran behavioral health and high-risk events, namely suicide attempts, incarceration, and homelessness. Using latent class analysis and a large, nationally representative sample of community veterans, the current study examined common patterns of veteran behavioral health disorders and the associations between these patterns and high-risk events. Results suggest four classes of veterans, including a “healthy” class (comprising 69% of the total sample), a “substance use disorder” class (16%), a “personality disorder-substance use disorder” class (8%), and a “depressive disorder” class (7%). Veterans in the healthy class had the lowest rates of suicide attempt (2%), incarceration (14%), and homelessness (3%), whereas veterans in the personality disorder-substance use disorder class had the highest rates of these events (27%, 45%, and 22%, respectively). Results attest to the importance of investing clinical resources into addressing the needs of veterans experiencing complex behavioral health patterns, particularly personality and substance use disorders. Implications for the health care of veterans are discussed.
Authors: Emily R. Edwards, PhD; Sarah Barnes, PhD; Usha Govindarajulu, PhD; Joseph Geraci, PhD; Jack Tsai, PhD
http://dx.doi.org/10.1037/ser0000488
2020
Connecting Mental Health Court Participants With Services: Process, Challenges, and Recommendations
Mental health courts are an increasingly common option for defendants whose mental health impedes the effectiveness of traditional justice processing. Determinations of eligibility for mental health court are informed by various sources, including consideration of the availability of community-based services. When the range, scope, or heterogeneity of community-based services is limited, some otherwise eligible defendants are unable to connect with appropriate services. For defendants with difficult-to-treat conditions (e.g., active suicidality, personality disorders), this challenge of connecting with services is especially difficult. This article discusses the challenges of connecting mental health court participants with appropriate services and proposes recommendations to mitigate these challenges. Recommendations include the establishment of specialized treatment programs, ensuring treatment programs are informed by the risk-need-responsivity model of criminal recidivism, trauma and cultural considerations, use of integrated case management services, and implementation of flexible treatment mandates.
Authors: Emily R. Edwards, PhD: D. R. Gina Sissoko, MA; Dylan Abrams, MA; Daniel Samost, MA; Stephanie La Gamma, PsyD; Joseph Geraci, PhD
