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

AuthorStephanie Singer,David A. Smelson,Stephanie Hartwell,Leon Sawh,Debra A. Pinals,Nathan Guevremont,Carl Fulwiler,William Fisher,Henry J. Steadman
Published date01 December 2015
Date01 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
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
World Medical & Health Policy, Vol. 7, No. 4, 2015
1948-4682 #2015 Policy Studies Organization
Published by Wiley Periodicals, Inc., 350 Main Street, Malden, MA 02148, USA, and 9600 Garsington Road, Oxford, OX4 2DQ.
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
( 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
330 World Medical & Health Policy, 7:4

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