An Alternative to Incarceration: Co‐Occurring Disorders Treatment Intervention for Justice‐Involved Veterans

• Author: Stephanie Singer,David A. Smelson,Stephanie Hartwell,Leon Sawh,Debra A. Pinals,Nathan Guevremont,Carl Fulwiler,William Fisher,Henry J. Steadman
• DOI: http://doi.org/10.1002/wmh3.168
• Published date: 01 December 2015
• Date: 01 December 2015

An Alternative to Incarceration: Co-Occurring Disorders

Treatment Intervention for Justice-Involved Veterans

David A. Smelson, Debra A. Pinals, Leon Sawh, Carl Fulwiler,

Stephanie Singer, Nathan Guevremont, William Fisher, Henry J. Steadman,

and Stephanie Hartwell

This article reports on the implementation, evaluation, and policy implications of MISSION-

Criminal Justice (CJ), an innovative intervention used to treat justice-involved veterans with co-

occurring mental health and substance use disorders (CODs). In this pilot feasibility study,

MISSION-CJ was embedded into four Massachusetts courts and their probation services as an

alternative to incarceration. Seventy-six veterans were diverted from jail to MISSION-CJ and

completed intake and six-month follow-up assessments. The MISSION-CJ participants were

primarily white, had at least two prior arrests, served in a war combat zone, had a trauma before

age 18, and had previously received mental health and substance use treatments. Preliminary six-

month follow-up data suggested that the MISSION-CJ participants showed improvements in COD

problems, trauma symptoms, and a nonsignif‌icant reduction in hospitalization/ER visits.

MISSION-CJ was feasible to implement and seemed to show some preliminary program success. A

randomized controlled trial of MISSION-CJ is a necessary next step in determining program

eff‌icacy. Policy implications for tailoring interventions for justice-involved veterans such as

MISSION-CJ and their delivery alongside the court and probation are discussed.

KEY WORDS: justice-involved veterans, alternatives to incarceration, co-occurring disorders treat-

ment, case management, risk-need-responsivity

Introduction

In the United States, in 2013, an estimated 6,899,000 individuals were in state

and federal prisons, local jails, or on probation or parole (Glaze & Kaeble, 2013).

Of those who were incarcerated, recent estimates suggest that nearly two-thirds

have substance use disorders (Fox et al., 2015), and over one million have mental

illnesses (Skeem, Manchak, & Peterson, 2011). In local jails, the presence of co-

occurring mental health and substance use disorders (COD) are as high as 75–

80% (Skeem, Steadman, & Manchak, 2015). One offender subpopulation of

particular interest to policymakers is military veterans. In 2007, roughly 200,000

veterans were incarcerated, comprising approximately 10 percent of the U.S. jail

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and prison inmate population (Elbogen et al., 2012; Finlay et al., 2014; Noonan &

Mumola, 2007; Tsai, Rosenheck, Kasprow, & McGuire, 2014), and recent national

Veterans Affairs (VA) justice outreach program data found that nearly 60 percent

of veterans had a COD (Finlay et al., 2014).

Due to both the high costs associated with incarceration and the high rates of

COD among justice-involved populations, a number of alternatives to incarcera-

tion programs are in use throughout the criminal justice system (Finlay et al.,

2014; Piquero, 2010). These programs, sometimes called “jail diversion,” share a

common goal of moving individuals out of the criminal justice system and into

treatment services. Moving individuals out of the criminal justice system is done

because this system is not a suitable substitute for needed behavioral health

treatments (Case, Steadman, Dupuis, & Morris, 2009).

The literature on alternative to incarceration programs demonstrates that they

provide a number of positive benef‌its to society, the individuals served, and

the criminal justice system. A recent economic analysis of a national cohort of

offenders diverted from prison to drug treatment found societal cost benef‌its of

$22.5 billion dollars and criminal justice savings of $12.9 billion dollars when

diverting 40 percent of eligible offenders (Zarkin et al., 2012). In another study,

individuals with mental illness diverted from jail to community-based services

had fewer arrests and days in jail in the 12 months following enrollment in a

diversion program (Case et al., 2009).

As part of the array of programs that operate as alternatives to incarceration,

drug courts and mental health courts are designed to link offenders to needed

treatment services in the community (Steadman, Davidson, & Brown, 2001). These

courts have yielded a number of positive outcomes including reductions in

recidivism and substance use, and improved psychological functioning (Knudsen

& Wingenfeld, 2015). Veterans Treatment Courts (VTCs) are a recent adaptation of

drug and mental health specialty court sessions, designed to better address the

problems faced by justice-involved veterans with mental health and substance use

disorders (Knudsen & Wingenfeld, 2015; Russell, 2009). Initially developed in

Buffalo, New York in 2008, there are now over 200 VTCs in the United States

(justiceforvets.org). Throughout the United States, VTCs share a number of

common practices, including a specialized court docket with regular appearances

in front of a judge who oversees the VTC session and monitors participant

compliance. To date, very limited data have been published on the success of

VTCs in achieving desired treatment and criminal justice outcomes. In one recently

published pilot study of a VTC providing specialized services to justice-involved

veterans with trauma issues, program participants experienced signif‌icant

improvements in trauma symptoms, substance abuse outcomes, and emotional

well-being at 6- and 12-month follow-up (Knudsen & Wingenfeld, 2015).

Although VTCs have increased in numbers across the country, not all court

districts hold a specialized VTC session, and most VTCs do not deliver mental

health and substance use treatment services directly within the court. In fact, they

rely largely on referrals to nonspecialized mental health and substance use

treatment services without specif‌ic programming for court-involved clients. Wolff

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