A Qualitative Examination of the Experiences of Veterans Treatment Court Graduates in Allegheny County,Pennsylvania

Abstract

U.S. Veterans treatment courts (VTCs) serve justice-involved Veterans with behavioral health and reintegration issues. However, there is paucity of efforts examining VTC participants’ experiences and distinguishing the unique operations of VTCs. We summarize a descriptive history of a large VTC program in a major metropolitan area (Pittsburgh, Pennsylvania) and examine the experiences of this VTC’s participants. We used content analysis to code VTC graduation proceeding transcripts with complementary content data from resources distributed by the presiding Judge to entering participants. From 2009 through 2016, 118 Veterans were graduated, averaging 9 to 12 months for completion for those with felony or non-felony charges, and blended monitoring with positive reinforcement within a three-stage program. From 62 VTC graduates across eight graduations, testimonies centered on gratitude toward the treatment team, treatment readiness, treatments received, and reintegration. As several theoretical frameworks on behavior change exist, opportunities remain to enhance the delivery of the VTC.

Keywords

qualitative research Veterans treatment courts court operations behavioral change

As reported by the U.S. Bureau of Justice Statistics, the United States supervises over 6.5 million individuals in the correctional system (Kaeble & Glaze, 2016). Those who are incarcerated in prisons and jails comprised approximately 32% of the total correctional population (Kaeble & Glaze, 2016). Veterans comprise 10% of the total incarcerated population, a number and proportion that has been declining over the last decade (Bronson, Carson, Noonan, & Berzofsky, 2015; Noonan & Mumola, 2007). However, beyond incarcerated Veterans, it remains unclear the total numbers of Veterans who are “justice-involved”—that is, those individuals who remain under correctional supervision via community corrections such as probation and parole. Despite the large population of incarcerated individuals in the United States, most individuals under correctional supervision are not incarcerated, but rather comprise the 67% of the total correctional population under adult probation and parole (Kaeble & Glaze, 2016). The number of Veterans who are justice-involved is therefore also underestimated given the unknown numbers of Veterans under the supervision of probation and parole.

Identifying effective treatment approaches for individuals who are involved in the criminal justice system is important given the related issue of recidivism, which has been defined as rearrest, reconviction, or reincarceration for a new crime or violation of the terms of one’s parole or probation (Durose, Cooper, & Snyder, 2014). It has been estimated that 68% of all state prisoners were arrested within 3 years of release and 77% were arrested within 5 years of release (Durose et al., 2014). While recidivism data are lacking for Veterans, it has been reported by the Veterans Health Administration (VHA) Justice Programs that their Veteran participants have experienced a lifetime average of five to eight arrests (Department of Veterans Affairs, 2014; Timko et al., 2014). Recent studies have examined recidivism risk factors posed to Veterans and have systematically reviewed interventions that adhere to the Risk-Need-Responsivity (RNR) model which states that treatments should be reserved for those highest at risk for recidivism and takes into account unique characteristics of the individual offender (Andrews & Bonta, 2010; Andrews, Bonta, & Hoge, 1990; Andrews, Bonta, & Wormith, 2006). Studies have reported on promising cognitive-behavioral treatments that may be appropriate to change antisocial thinking, though these treatments should be appropriately adapted to Veterans’ characteristics and military experiences and should first undergo an evaluation of implementation to Veteran populations (Blonigen et al., 2016; Timko et al., 2014). There are special considerations with programs and treatment options to help reduce the recidivism of justice-involved Veterans that pay particular attention to the contextual factors of military culture, civilian reintegration, and implications of combat experiences (Timko et al., 2014).

For some Veterans, involvement with the justice system may stem from an underlying mental illness or substance abuse problem (Huskey, 2015). In fact, the numbers of Veterans who appear on specialized court dockets—which are sessions of court that offer a therapeutically oriented judicial approach to providing court supervision and treatment to individuals—have increased. Due to this increase, special problem-solving courts, such as Veterans treatment courts (VTC), have emerged throughout the United States, and today, as many as 461 exist, with others in various stages of planning, development, and implementation (Baldwin, 2015; Edelman, 2016; Flatley, Clark, Blue-Howells, & Rosenthal, 2016; McGuire, Clark, Blue-Howells, & Coe, 2013). VTCs are specialty courts that are characterized by a shared belief in treatment over incarceration, and VTCs allow jurisdictions to dedicate a court or docket to serve Veterans who are involved in the criminal justice system. VTCs are championed by a judge and consist of a multidisciplinary team who are familiar with available Veterans’ resources and treatment issues, and admit Veterans with a range of conditions related to substance use and mental health challenges. VTCs have been adopted across the country as a program modality that facilitates a participants’ interface with Veterans Affairs (VA) health care, VA benefits, the corrections system, and legal systems. Thus, VTC participants enter a program dedicated to advance their recovery and stability throughout their reentry into civilian life (Edelman, 2016). As defined by the Substance Abuse and Mental Health Services Administration (SAMHSA, 2012), recovery is a “process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” VTC courts, in theory, can participate in recovery efforts.

The Present Study

In the face of rapid adoption of this court modality and the increasing numbers of Veterans who are participating in this court treatment, there remains a need to learn more about the unique operations of VTCs in specific jurisdictions around the country as well as efforts to report on participants’ subjective experiences in the VTC. Therefore, given the descriptive history and context of justice-involved Veterans, the aim of this study to inform on VTC graduates’ experiences with the Allegheny County, Pennsylvania, VTC program.

The Allegheny County VTC is a separately designated VTC and has been an operational VTC since November 2009. Between 2009 and 2016, the VTC has graduated 118 Veteran participants. Among these 118, there were 113 males (96%) and five females (4%). The following provides a summary of the VTC operations—information which is also presented to new Allegheny County VTC participants in the form of a packet of resources that are distributed to Veterans upon acceptance into this VTC program.

Eligibility

The Allegheny County VTC operates under their commitment to “No Veteran Left Behind.” This is a unique component to this VTC as approximately 60% of VTCs did not report operating under a mission statement (Baldwin, 2015). The Allegheny County VTC accepts misdemeanors and felonies, and also considers eligibility for participation among violent offenders and domestic violence offenders. Both pre-plea and post-plea are accepted. The Allegheny County VTC meets weekly, and the average length of time for Veterans to complete the Allegheny County VTC program has been 9 to 12 months (D. Barnisin-Lange, personal communication, July 7, 2017). Its jurisdiction is Allegheny County under the purview of the Fifth Judicial District Pennsylvania Court of Common Pleas. The Allegheny County VTC periodically accepts supervision for out of county cases when it is acceptable and agreed upon by both jurisdictions, for persons with other county supervision, and who currently live in Allegheny County (D. Barnisin-Lange, personal communication, July 7, 2017).

Eligibility criteria to participate in this court are neither restricted by the requirement for substance use or mental health diagnoses, nor is it restricted by a determination that the mental health condition be related to military service. This VTC is not restricted to Veterans with combat exposure and includes active duty service members and reservists and guards without active service. Veterans eligible for Allegheny County VTC are not required to be eligible for VA health care, and since this court’s inception, 10% of admitted Veterans have been deemed by the assessment of the court’s Veteran Justice Outreach (VJO) specialist to be ineligible for VA health care services. In these cases, the VTC has enlisted the support of the Allegheny County Office of Behavioral Health, local Veteran agencies such as the Vet Center and Veterans Leadership Program of Western Pennsylvania, to intervene and provide services for qualified Veterans who are ineligible for VA services (D. Barnisin-Lange, personal communication, July 7, 2017). This VTC does not currently allow other defendants, including family members, non-Veteran VA employees, and non-U.S. military. The broad categories for participant eligibility are specific to the jurisdiction of this VTC. VTCs across the United States actually may vary widely in the specific charges or charge categories, including exclusions for various criminal statuses, types of charges and sentences, injury to victim, treatment needs, and previous VTC participation (Baldwin, 2015).

VTC Treatment Team

The VTC functions as a multidisciplinary team that meets weekly to review Veterans’ progress and ongoing treatment needs. A full treatment team consists of a dedicated presiding Judge who oversees all court proceedings and decisions regarding VTC cases and participants; a District Attorney (DA) who closely reviews and evaluates each case to determine appropriate offers, agreements, sentences, and supervision; defense partners who are counsels who represent the Veterans in all aspects of their criminal case reviews; a dedicated probation officer who oversees the supervision of sentence and probation compliance; a VJO specialist who is charged to ensure service connection to mental health and substance use treatment; a mentor coordinator who recruits, trains, and matches Veterans with a mentor; representatives from the Office of Behavioral Health and Justice Related Services (JRS) to assist Veterans who are not eligible for VA Services or who opt-out of VA care; a representative from the Vet Center provides readjustment counseling and outreach services to all Veterans who served in any combat zone; and a representative from the Veterans Leadership Program of Western Pennsylvania, a community provider that offers services and support to Veterans including housing, employment, and case management (Allegheny County Veterans Treatment Court, n.d.); a VA Benefits representative; a local recovery coordinator; a representative from the VA’s Mental Illness Research, Education, and Clinical Centers (MIRECC); and other Veteran services providers such as PA Serves may also be present during court sessions. To expand on the VJO, the VJO program is a national program consisting of VA employees who are clinical specialists that provide referrals to Veterans in courts and jails into VA treatment (U.S. Department of Veterans Affairs, 2017). The VJO specialist coordinates VA care for the court and advocates for each Veteran to connect with appropriate services, treatment, and providers. A VJO specialist is always present in person at each court session, and an individual VJO specialist may average 20 hours a month interacting with the court team in addition to those days when court is in session.

Individualized Service Plan (ISP)

In the Allegheny County VTC, Veteran participants, along with VJO specialists, create an ISP that serves as a contract delineating the treatment expectations and conditions of probation for the Veteran while in the VTC. The ISP details the importance for the Veteran to stay in contact with the VJO specialist and his or her probation officer, to take all prescribed medications, to indicate where a Veteran will attend treatments, to inform where the Veteran will reside, and to place limitations, as needed, on whom Veterans may contact or any geographical areas (Allegheny County Veterans Treatment Court, n.d.). As the VJO specialist and the Veteran’s probation officer maintain contact with all treatment team members and always participate in court sessions, the VJO specialist and probation officer provide a participant update to the court during hearings. Each review is characterized as positive, neutral, or negative depending on the Veteran’s compliance with the service plan expectations (Allegheny County Veterans Treatment Court, n.d.).

Movement Through the VTC Program

Progress through the Allegheny County VTC is facilitated by its three-stage model that blends monitoring with positive reinforcement for compliant participants (Figure 1). Once participants are deemed eligible and have accepted the terms of the program, they are informed that monitoring one’s progress is a critical component and that he or she is required to attend in-court reviews throughout the duration of his or her participation in the program. Through each of three separate phases, Veterans receive support and encouragement from all treatment team members to ensure the Veteran’s success in meeting phase requirements. As participants demonstrate increased insight and compliance to their probation and service plans, Veterans are rewarded with reduced court reviews, less supervision restrictions, and receipt of a VTC dog tag to mark one’s success in that phase. The court notifies the VTC participants that it employs increasing positive reinforcement and rewards for compliance and progress, and escalating negative consequences when Veterans are non-compliant with stated rules and expectations of the court. The court’s participant packet described consequences including increased court reporting, increased drug testing, mandated inpatient treatment, house arrest, and incarceration.

Figure 1.

Phases of Allegheny County, PA, VTC program.

Method

This study was considered as nonhuman subjects research by the Institutional Review Board and the Research and Development Office at the VA Pittsburgh Healthcare System (VAPHS). Court transcripts included information for VTC graduates from VTC graduation proceedings between November 2009 and November 2016. In Allegheny County’s VTC, graduations are an annual ceremony that recognizes accomplishments of Veterans completing the VTC program and complementary contributions of the VTC treatment team. During these VTC graduations, Veterans who are graduating from the program have an opportunity to share reflections on their experience.

Study Setting

The Commonwealth of Pennsylvania (PA) is home to nearly 1 million Veterans. It is a state with a VA health care network of 153 hospitals, 773 community-based outpatient clinics, 260 Vet Centers, 135 nursing homes, 47 residential rehabilitation programs, and 121 home care programs (Department of Veterans Affairs, 2010). Pennsylvania has been referred to as a leader in the VTC movement as it hosts a large number of VTCs in the United States (Ahlin & Douds, 2016): in 2017, the Commonwealth of Pennsylvania was home to 20 operational VTCs, one mental health court with a designated Veterans-track, and one regional drug court serving three counties with a designated Veterans-track (Unified Judicial System of Pennsylvania, 2017).

Since November 2009, the Allegheny County VTC assists eligible and participating Veterans with a supportive multidisciplinary team approach that facilitates resources for recovery. The Allegheny County VTC has been in continuous operation for 8 years, and since its inception has seen more than 150 Veterans in varying stages of recovery from addiction, mental illness, and community and civilian reintegration.

Data Coding and Analysis

Content data for this study included a copy of a packet of resources created and distributed to Veterans upon acceptance into VTC by the presiding Judge. Upon acceptance and admission into the Allegheny County VTC, Veterans receive an informational packet that consists of a signed letter from the presiding judge welcoming the Veteran into the treatment court, a sample service plan, a VTC participant handbook, a crisis hotline quick reference card, a brochure and information sheet from the Veterans Leadership Program (which provides employment and educational opportunities for Veterans), and an informational DVD titled Inside Allegheny County Veterans Court. Veterans who are entering this VTC as a participant are assigned a VJO specialist.

The narrative data for this study included existing, publicly available VTC graduation transcripts dated between November 2009 and November 2016. Content analysis using the grounded theory approach of constant comparison was used to code and assess the narrative data of the VTC graduation transcripts to create a descriptive summary. The primary author acquired copies of original transcripts and then typed verbatim into an Excel spreadsheet all extracted comments made by individual graduating Veterans from the transcripts. This spreadsheet was then used to help researchers codify the topics expressed during the graduation proceedings.

Two members of the research team evaluated for major emergent topics across graduates. The coders read and re-read the data and generated a codebook to document topics of discussion and supporting content which could be applied and used to compare coding, assisting with resolution of discrepancies. The codebook was developed by reading the first 20% (n = 12) of the graduates’ testimonies and retaining all codes. Subsequent groups of 12 transcripts were reviewed for constant codes and emergence of new codes. This constant comparison method was maintained until refinement of topics was achieved. The researchers met to compare and resolve any discrepancies using a negotiated consensus approach (Bradley, Curry, & Devers, 2007).

Results

If you are sitting here graduating, you earned it because, you know, you look at anyone else who gets sentences, and they go to jail, and they get out, and they’re free. You didn’t just plead into Veterans court. . .you accepted raising the bar on your life and taking the opportunity to grow, which is not an easy road to take. It took me two years to realize that. (Testimony given by graduating Veteran from Allegheny County VTC)

Emergent Topics Among Participant Narratives

In addition to the content review of the VTC participant packet and descriptive history, the study team reviewed 62 contributions from VTC graduates across eight transcribed VTC graduation proceedings dated between November 2009 and November 2016 from the Allegheny County VTC in Pennsylvania (Table 1). All were coded and thematic saturation was achieved after analyzing data from 48 of the 62 individuals (Creswell & Poth, 2017).

Table 1.

Emergent Themes and Subcategories Across Eight Graduation Proceedings for 62 VTC Graduates.

Theme	Representative quotes
1. Expressing gratitude
Toward VTC as “opportunity”	“I appreciate getting the opportunity to complete this program”
	“Thank you for giving me the opportunity to succeed. . . with the help of Veterans court my life has changed, and I have been clean today for 28 months. Thank you.”
Toward treatment team	“I just wanted to thank Judge Zottola and for everyone that helped me. . . sometimes you still have other people that care about you.”
	“I just want to thank you. Thanks to everybody. This is probably the one place where you’re going to find people who actually bend over backwards to help you out.”
2. Movement through stages of change/treatment readiness
Stage 1: Precontemplation	“Initially, when I started I didn’t think it would be that way. . . I have learned a lot. . . I couldn’t ask for a better outcome.”
	“I wasn’t ready to make any real changes to my life. . . I was finally able to snap out of it. . . I made a decision. . . my life is a lot different today than it ever has been before.”
Stage 2: Contemplation	“I’d like to thank Veterans court. . . I’ve had ups and downs. Everybody says second chances. I’ve had more than second chances.”
	“I really laughed [VTC] off as a joke. . . well, for the next two years I was pretty bitter about coming here. . . but the Veterans court actually helped me. . . it kept me long enough to where I could find the right tools to be successful.”
Stage 3: Preparation	“I did drugs and drank for 20 years. . . I succeeded and failed and succeeded and failed. . . I was able to get help. . . I realized it was pretty empowering to be sober and clean and started to think and feel good about myself.”
	“Well things started off really tough at first. . . it took about ‘til January of this year to realize my way doesn’t work. . . so [Judge Zottola] has given me so many chances. . .”
Stage 4: Action	“I made a decision that no matter what happened, I was going to, for the first time in my life, give 100% effort at staying clean and sober and trying to learn something different . . . my life is a lot different than it ever has been before.”
	“So it’s about the new chapter, and I’m excited and thrilled. . .”
Stage 5: Maintenance	“I’ve really been trying to live every day better than the day before and really trying to do the next right thing.”
	“I finally joined the fight for my life. . . I’m doing things today that I haven’t done in 25 years.”
3. Services and treatments received	“. . . throughout this process of the Veterans court and all the support from the VA people and all the different programs. . . ”
	“I found a whole stack of business cards, all those guys that I worked with that helped me, and what’s really important is to remember that they’re still there, to use those numbers, because you never know when you’re going to need them.”
4. Reintegration/Return to civilian life	“My bills are paid for 30 days, I’m overwhelmed, and I’m grateful to come through here.”
	“[VTC] gave me an opportunity to see what it’s like to be clean and sober for a stretch of a year and a half. . . It’s a lot nicer to be able to have a job and have a couple dollars in your pocket.”
	“I want to thank my parents for supporting me through my darkest times.”

Note. VTC = Veterans treatment courts.

Gratitude

First, nearly all VTC graduates expressed gratitude and their statements were distinctly directed at two specific subtopics. There were 11 graduates that expressed global appreciation at the VTC opportunity; for example, one Veteran stated, “I appreciate getting the opportunity to complete this program” and another Veteran stated, “Thank you for giving me the opportunity to succeed.” However, the majority of gratitude was directed at the role of the VTC treatment team and its members. Among 62 graduates, 52 (84%) referenced the treatment team. For example, two different VTC graduates noted:

I just wanted to thank Judge Zottola and you, sir, for everyone that helped me. The most important thing I got out of the system here was if you don’t care about yourself, sometimes you still have other people that care about you and can help you care about yourself.

. . .including [the Judge], and I really appreciate [VJO specialist], man. This man showed me fatherlike ways and of course within the realms of being able to help me, and I’m like indebted to you forever. You know, you really don’t know how much you like, showed me and showed me how to live, you know. You gave me a lot of direction. . .and when you give somebody direction, you know, it’s—now on them. You gave me a totally different attitude. You motivated me. I became more disciplined. . . I’m like really, really thankful that vets court was so patient with me.

Reflections of Moving Toward Treatment Readiness

A second topic emerged in graduates’ references to their treatment readiness journey. In our study, 36 graduates (58%) discussed moving through various stages of readiness to engage in VTC treatments during their journey through the program. For example, one graduate shared,

. . .the process I’ve been through here. . . I was a loser for many years. . . at that point in my life. . . in the beginning and for many months. . . a little over two years ago. . . here I am two years later, and I can’t think of one good reason to die.

Another graduate noted,

I wasn’t ready to make any real changes in my life to get out of that trouble. . . I still believed that if I just do it differently this time, I will be able to keep drinking and getting high with no consequences. . . then a lot has changed for me. . . I was finally able to snap out of it. . . it was the lowest point in my life. . . I made a decision. . . my life is a lot different today than it ever has been before.

Services and Treatment Received

A third topic discussed by 16 (26%) graduates was types of treatments and services received via the VTC program. Among our VTC participants in Allegheny County, one example of a graduates’ testimony described his return from service alongside “all the support from the VA people and all the different programs.” Another graduate offered the specifics of his experience by noting,

Veterans court gave me one more chance at treatment. This time I went into a day inpatient and six-month halfway house. I learned a lot about recovery and about myself while in treatment. When I was done with the halfway house, I volunteered to go into a three-quarter house. This greatly benefitted me. Just the fact that I would volunteer to go to a structured environment proved to myself that I had changed. My life is a lot different today than it ever has been before.

Community Reintegration

A fourth topic referenced his or her successful reintegration. In our study, we found that references to community reintegration were discussed among 13 (21%) Veterans. This topic included Veterans’ experiences with particular characteristic of civilian life, such as the acquisition of material items, mention of engaging in relationships with family, and re-engaging in employment role functions. For example, selected excerpts include “I thank God that I’m alive, and that I’m not living under that bridge,” “my kids want to thank you,” “it’s a lot nicer to be able to have a job and have a couple dollars in your pocket,” and “I have my family back. I am learning a trade right now that I love to do and could lead to great success someday.”

Discussion

The VTC is a structured program designed to serve justice-involved Veterans with addiction and substance use issues, mental health issues, and reintegration issues. The goals of this secondary analysis were to report on Veteran’s experiences with a VTC program. This study identified four major topics among the testimonies of VTC graduates including (a) expressed gratitude to the treatment team and/or gratitude for the VTC program opportunity; (b) movement through stages of change/treatment readiness; (c) reports of the services and treatment received through VTC efforts; and (d) perspectives on reintegration and the experience of returning to civilian life.

First, Allegheny County, PA, VTC’s graduates expressed gratitude directed at the treatment team. This finding suggests that VTC participants are interacting and perceiving the role of the treatment team in the manner envisioned for the VTC. VTC teams are characteristically accommodating of its Veteran participants, collaborative, and team-oriented which are characteristics that do not follow the traditional adversarial approach (Baldwin, 2015; Edelman, 2016). VTC treatment teams are multidisciplinary in function and its individual members’ roles stem from judicial and legal, assessment and treatment, and recovery and social support services (Baldwin, 2015; McGuire & Clark, n.d.; Russell, 2009). However, despite the consistency in this single-site VTC’s findings, practitioners should remain cognizant of issues that may challenge the operations within other VTCs such as understaffing, underfunding, and the impact of potentially strained relationships with the Department of Veterans Administration (Baldwin, 2014).

Second, Allegheny County VTC’s graduates made reference to his or her treatment readiness journey during their time in the Allegheny County VTC program. Many Veterans were not prepared to confront their need for behavioral health treatment until well into the VTC program. The testimony documenting Veterans’ transformation during their VTC experience evokes similar language to models of treatment readiness and the concept of a journey through varied stages of change (Burrowes & Needs, 2009; Casey, Day, & Howells, 2005; Day, Bryan, Davey, & Casey, 2006; Prochaska & DiClemente, 1982; Prochaska, DiClemente, & Norcross, 1992; Yong, Williams, Provan, Clarke, & Sinclair, 2015). The abilities of a VTC graduate to reflect on his or her treatment journey and to recognize the purposeful behavior changes made during the treatment process are important observations. Moreover, while one of the goals of VTC is to address the underlying behavioral health problems that have influenced the criminal justice involvement, it is the efforts of a dedicated treatment team to monitor the motivations and partner with the VTC participant for progress over time.

Third, Allegheny County, PA, VTC’s graduates made reference to the services and treatment received through VTC efforts. VTCs are founded on the idea that Veterans should have timely access to VA mental health and substance abuse services when clinically indicated and other VA services and benefits as appropriate (McGuire & Clark, n.d.). The long-term goal of the VTC is to reduce, and eventually eliminate, offending, while the immediate focus is on addressing the challenges faced by the participants’ underlying behavioral health and social support needs. One VTC study reported that participants may have access to a range of services including case management, outpatient mental health treatment, outpatient substance use treatment, physical therapy, psychiatric medication, peer mentor services, transportation services, housing services, trauma-specific treatment, residential substance use treatment, emergency room services, vocational services, and inpatient mental health services (Knudsen & Wingenfeld, 2016). However, treatment and service availability remain varied across jurisdictions. In addition, variability is also influenced by the geographical constraints of urban and rural communities where Veterans reside and where VTCs are located. However, as noted in Baldwin’s (2015) study, while VTCs may need a VA provider within a reasonable distance, the existence of the VA provider does not appear to be the single driving force in the creation of a VTC.

Finally, Allegheny County, PA, VTC’s graduates focused on their memories of successful reintegration during their graduation proceedings. Among Veterans, civilian reintegration is an appropriate term used for Veterans returning from deployment in the military. For Veterans, reintegration may be influenced by unpreparedness for civilian life, such as establishing financial stability, finding employment, and navigating civilian sectors of health care and social systems (Institute of Medicine, 2010). Veterans must also define their new normal during the reintegration experience which can be confronted by a reformulation of one’s identity between military, civilian, and Veteran (Ahern et al., 2015; Bobb, 2016; Demers, 2013; Koenig, Maguen, Monroy, Mayott, & Seal, 2014; Maiocco & Smith, 2016; Mankowski, Tower, Brandt, & Mattocks, 2015). Furthermore, for some Veterans, their new normal is confronted by unintended incarceration due to unlawful activities. For those justice-involved Veterans, the challenges of reintegration may also reveal other vulnerabilities stemming from behavioral health, substance use, and homelessness (Baldwin, 2015; Finlay et al., 2016; Larson & Norman, 2014; Millar, Aase, Jason, & Ferrari, 2011). Veterans returning to civilian life do experience challenges and health burdens which may result in involvement with criminal justice systems.

The areas of discussion by our Veteran graduates reflect the primacy of their individualized behavior change process, the effect of interaction with the treatment team and services received, and the importance of successful reintegration with their communities. These are all important considerations for how reintegrating Veterans must achieve “typical community life” following the release from an institutional setting such as a hospital or incarceration (Resnik et al., 2012). Per the recommendations stemming from a 2010 Working Group on Community Reintegration, 11 key dimensions of community reintegration are applicable for Veterans: participation in the role functions within social (friends and family engagement), work/employment, education/learning activities, parental roles, spouse/significant other relationships, spiritual/religious activities, leisure activities, domestic life activities, civic engagement, self-care activities, and economic life transactions were included as measures for human participation and involvement in society (i.e., community reintegration) (Resnik et al., 2012). To achieve these benchmarks of successful reintegration, Veterans shared their experiences of actively changing maladaptive behaviors. As suggested by various health promotion theoretical models including the health belief model (HBM) and the transtheoretical model/stages of change (TTM) (Glanz & Bishop, 2010), the choices made by Veterans were not random, but are associated with a marked change process. The HBM explains that an individuals’ beliefs about risk for a health problem and their perceptions of needing to avoid the risks are influenced by their readiness to make changes to their behavior (Rosenstock, 1974a, 1974b). Relatedly, the TTM theorized the need for individuals to sequentially partake in adaptive behaviors that lead to successful behavior change (DiClemente & Prochaska, 1982; Prochaska & DiClemente, 1982; Prochaska et al., 1992). While some critics argue the TTM does not allow an appropriate measurement of the motivations to change, the context of behavior change, and the measurement of the progression of change for offender populations (Burrowes & Needs, 2009; Casey et al., 2005; Day et al., 2006; Yong et al., 2015), there remains the importance of the change process which has resulted in the emergence of other forensic-specific change models. For example, the Readiness to Change Framework (RCF) differs from the TTM by focusing on what the individual may be contemplating rather than that the individual is contemplating, and explores why the individual is in the contemplation stage rather than simply that the individual is contemplating (Burrowes & Needs, 2009). Another treatment model is the Good Lives Model (GLM) which was initially developed as a model for use with male sexual offenders (Ward, Mann, & Gannon, 2007; Ward & Stewart, 2003) and later extended to work with male violent offenders (Whitehead, Ward, & Collie, 2007) and male domestic violence perpetrators (Langlands, Ward, & Gilchrist, 2009). GLM posits that an individual commits criminal offenses because he lacks the capacity to realize personally fulfilling outcomes in socially acceptable ways (Ward & Gannon, 2006; Ward et al., 2007). Given the existence of these change models, it appears there may be opportunities to apply change models into the treatment approach supported in the VTC as it may offer a framework to enhance and support the change process experienced by participants and suggest where the treatment team may fortify operations in anticipation of the readiness to change process experienced by their participants.

In summary, there were four memorable components of the VTC program that were recounted during graduation proceedings. It is suggested that given the existence of several theoretical frameworks on behavior change, there remain opportunities to enhance the delivery of the VTC applying adapted models of behavior change for Veterans facing behavioral health and community reintegration challenges. The joint efforts undertaken by the treatment team and the Veteran participant are notable in this treatment model and more research is encouraged to examine the perceptions of Veteran participants and to evaluate the success of the program.

Some limitations may have minimally influenced the results of our study. First, the generalizability of our qualitative data is limited due to the geographic specificity of this VTC as well as the relatively homogeneous sample in terms of gender. However, generalizability is not the purpose of qualitative research and instead qualitative methods seek a contextual understanding of the topic of study (Morse, 1999). A second potential limitation is that participants’ testimonies may have been influenced by social desirability as graduates spoke aloud in a court witnessed by peers, judges, attorneys, and other dignitaries. However, the research team thought this was minimal given that all testimonies were provided by completers of the VTC program and their status within the program would not be impacted. Finally, there is the potential for bias in the representativeness in the transcript data. The data included only graduating Veterans and did not include Veterans who did not complete the VTC. The potential bias may stem from the under-representation of those Veterans who were once participants but were not completers. Similar studies could balance this bias by being inclusive of Veterans who may have been terminated prematurely from the VTC program.

Concluding Remarks and Future Research

As expressed by one VTC graduate, the VTC experience allowed her to “finally [join] the fight for my life”—this quote may embody that critical role in the VTC of the Veteran as an active participant in his or her recovery and successful civilian reintegration. It remains important to document and disseminate information about the experience of a VTC from the perspective of the participant navigating his or her recovery and discharge from the criminal justice system. Through this study, we hope to contribute to the knowledge base and increase attention to the salient issues expressed by Veterans who have successfully completed VTC as well as to bring awareness to those participants who may have terminated prematurely from the VTC.

The attention to justice-involved Veterans and the treatment modality presented in the VTC model are gaining increased attention and the research body continues to expand. The VTC serves as a prime opportunity to gather feedback from Veterans who are involved in the criminal justice system and enrolled in programs focused on mitigating substance abuse, addiction, mental health issues, and reducing recidivism. As the present study did not delve into the recidivism statistics of these VTC graduates, future research is warranted to examine the potential longer term effects of components of the VTC, such as the treatment team’s engagement, the role of accessing behavioral health treatment, the relationship with the presiding judge, and the overall impact on reducing recidivism for VTC participants.

Footnotes

Acknowledgements

The authors thank the Honorable Judge John A. Zottola for technical assistance on this manuscript and his continued efforts with the Allegheny County, PA Veterans Treatment Court.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: Dr. McCall was supported with use of facilities at the Pittsburgh, VA and the Office of Academic Affiliations Advanced Fellowship in Women�s Health. The contents of this manuscript do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

ORCID iD

Keri L. Rodriguez

References

Ahern

Worthen

Masters

Lippman

S. A.

Ozer

E. J.

Moos

(2015). The challenges of Afghanistan and Iraq Veterans’ transition from military to civilian life and approaches to reconnection. PLoS ONE, 10, e0128599. doi:10.1371/journal.pone.0128599

Ahlin

E. M.

Douds

A. S.

(2016). Military socialization: A motivating factor for seeking treatment in a Veterans’ treatment court. American Journal of Criminal Justice, 41, 83-96. doi:10.1007/s12103-015-9332-4

Allegheny County Veterans Treatment Court. (n.d.). Veteran participant handbook. Pittsburgh, PA: VA Pittsburgh Healthcare System.

Andrews

D. A.

Bonta

(2010). Rehabilitating criminal justice policy and practice. Psychology, Public Policy, and Law, 16, 39-55.

Andrews

D. A.

Bonta

Hoge

R. D.

(1990). Classification for effective rehabilitation: Rediscovering psychology. Criminal Justice and Behavior, 17, 19-52.

Andrews

D. A.

Bonta

Wormith

J. S.

(2006). The recent past and near future of risk and/or need assessment. Crime & Delinquency, 52, 7-27.

Baldwin

J. M.

(2014). The Veterans treatment court concept in practice: Issues for practioners. Perspectives (0821-1507), 38, 74-92.

Baldwin

J. M.

(2015). Investigating the programmatic attack: A national survey of Veterans Treatment Courts. Journal of Criminal Law and Criminology, 105, 705-752.

Blonigen

D. M.

Bui

Elbogen

E. B.

Blodgett

J. C.

Maisel

N. C.

Midboe

A. M.

Timko

(2016). Risk of recidivism among justice-involved Veterans. Criminal Justice Policy Review, 27, 812-837.

10.

Bobb

(2016). Women Veteran identity and its impact on the use and preference of VA health care services and reintegration (Doctoral dissertation). Alliant International University, Sacramento, CA.

11.

Bradley

E. H.

Curry

L. A.

Devers

K. J.

(2007). Qualitative data analysis for health services research: Developing taxonomy, themes, and theory. Health Services Research, 42, 1758-1772.

12.

Bronson

Carson

E. A.

Noonan

Berzofsky

(2015). Veterans in prison and jail, 2011-12. Retrieved from http://www.bjs.gov/index.cfm?ty=pbdetail&iid=5479

13.

Burrowes

Needs

(2009). Time to contemplate change? A framework for assessing readiness to change with offenders. Aggression and Violent Behavior, 14, 39-49.

14.

Casey

Day

Howells

(2005). The application of the transtheoretical model to offender populations: Some critical issues. Legal and Criminological Psychology, 10, 157-171.

15.

Creswell

J. W.

Poth

C. N.

(2017). Qualitative inquiry and research design: Choosing among five approaches (4th ed.). Washington, DC: Sage.

16.

Day

Bryan

Davey

Casey

(2006). The process of change in offender rehabilitation programmes. Psychology, Crime & Law, 12, 473-487.

17.

Demers

A. L.

(2013). From death to life: Female Veterans, identity negotiation, and reintegration into society. Journal of Humanistic Psychology, 53, 489-515. doi:10.1177/0022167812472395

18.

Department of Veterans Affairs. (2010). State summary: Pennsylvania and the U.S. Department of Veterans Affairs. Retrieved from https://www.va.gov/opa/publications/factsheets/ss_pennsylvania.pdf

19.

Department of Veterans Affairs. (2014). VA’s Veterans Justice Outreach program: Services for Veterans involved in the justice system Retrieved from https://www.nami.org/getattachment/Extranet/Education,-Training-and-Outreach-Programs/Signature-Classes/NAMI-Homefront/HF-Additional-Resources/HF15AR5VetJusticeOutreach.pdf

20.

DiClemente

C. C.

Prochaska

J. O.

(1982). Self-change and therapy change of smoking behavior: A comparison of processes of change in cessation and maintenance. Addictive Behaviors, 7, 133-142.

21.

Durose

M. R.

Cooper

A. D.

Snyder

H. N.

(2014). Recidivism of prisoners released in 30 states in 2005: Patterns from 2005 to 2010 (Bureau of Justice Statistics Report NCJ 244205). Washington, DC: U.S. Department of Justice.

22.

Edelman

(2016, May). Veterans treatment courts: A second chance for vets who have lost their way (Accession No. 13CS20A001). Washington, DC: U.S. Department of Justice, National Institute of Corrections.

23.

Finlay

A. K.

Smelson

Sawh

McGuire

Rosenthal

Blue-Howells

. . . Harris

A. H. S.

(2016). U.S. Department of Veterans Affairs Veterans Justice Outreach program: Connecting justice-involved Veterans with mental health and substance use disorder treatment. Criminal Justice Policy Review, 27, 203-222.

24.

Flatley

Clark

Rosenthal

Blue-Howells

. (2017). Veterans court inventory 2016 update: Characteristics of and VA involvement in Veterans Treatment Courts and other Veteran-focused court programs from the Veterans Justice Outreach Specialist Perspective. Washington, DC, US Department of Veterans Affairs, Veterans Health Administration, March 2017. Retrieved from https://www.va.gov/HOMELESS/docs/VJO/2016-Veterans-Court-Inventory-Update-VJO-Fact-Sheet.pdf

25.

Glanz

Bishop

D. B.

(2010). The role of behavioral science theory in development and implementation of public health interventions. Annual Review of Public Health, 31, 399-418.

26.

Huskey

K. A.

(2015). Reconceptualizing “the crime” in Veterans treatment courts. Federal Sentencing Reporter, 27, 178-186. doi:10.1525/fsr.2015.27.3.178

27.

Institute of Medicine. (2010). Returning home from Iraq and Afghanistan: Preliminary assessment of readjustment needs of Veterans, service members, and their families. Washington, DC: The National Academies Press.

28.

Kaeble

Glaze

L. E.

(2016). Correctional population in the United States, 2015 (Bureau of Justice Statistics Report NCJ 250374). Washington, DC: U.S. Department of Justice.

29.

Knudsen

K. J.

Wingenfeld

(2016). A specialized treatment court for Veterans with trauma exposure: Implications for the field. Community Mental Health Journal, 52, 127-135. doi:10.1007/s10597-015-9845-9

30.

Koenig

C. J.

Maguen

Monroy

J. D.

Mayott

Seal

K. H.

(2014). Facilitating culture-centered communication between health care providers and Veterans transitioning from military deployment to civilian life. Patient Education and Counseling, 95, 414-420. doi:10.1016/j.pec.2014.03.016

31.

Langlands

R. L.

Ward

Gilchrist

(2009). Applying the good lives model to male perpetrators of domestic violence. Behaviour Change, 26, 113-129.

32.

Larson

G. E.

Norman

S. B.

(2014). Prospective prediction of functional difficulties among recently separated Veterans. Journal of Rehabilitation Research & Development, 51, 415-427. doi:10.1682/jrrd.2013.06.0135

33.

Maiocco

Smith

M. J.

(2016). The experience of women Veterans coming back from war. Archives of Psychiatric Nursing, 30, 393-399. doi:10.1016/j.apnu.2016.01.008

34.

Mankowski

Tower

L. E.

Brandt

C. A.

Mattocks

(2015). Why women join the military: Enlistment decisions and postdeployment experiences of service members and Veterans. Social Work, 60, 315-323. doi:10.1093/sw/swv035

35.

McGuire

Clark

Blue-Howells

Coe

(2013). An inventory of VA involvement in Veterans courts, dockets, and tracks. Retrieved from http://www.justiceforvets.org/sites/default/files/files/An%20Inventory%20of%20VA%20involvement%20in%20Veterans%20Courts.pdf

36.

McGuire

Clark

(n.d.). Veterans Justice Outreach Initiative (VJO). Washington, DC: U.S. Department of Veterans Affairs, Veterans Health Administration.

37.

Millar

J. R.

Aase

D. M.

Jason

L. A.

Ferrari

J. R.

(2011). Veterans residing in self-governed recovery homes for substance abuse: Sociodemographic and psychiatric characteristics. Psychiatric Rehabilitation Journal, 35, 141-144. doi:10.2975/35.2.2011.141.144

38.

Morse

J. M.

(1999). Qualitative generalizability. Qualitative Health Research, 9, 5-6.

39.

Noonan

M. E.

Mumola

C. J.

(2007). Veterans in state and federal prison, 2004 (Bureau of Justice Statistics Special Report NCJ 217199). Washington, DC: U.S. Department of Justice.

40.

Prochaska

J. O.

DiClemente

C. C.

(1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research & Practice, 19, 276-288.

41.

Prochaska

J. O.

DiClemente

C. C.

Norcross

J. C.

(1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1102-1114.

42.

Resnik

Bradford

D. W.

Glynn

S. M.

Jette

A. M.

Johnson Hernandez

Wills

(2012). Issues in defining and measuring Veteran community reintegration: Proceedings of the working group on community reintegration, VA Rehabilitation Outcomes Conference, Miami, Florida. Journal of Rehabilitation Research & Development, 49, 87-100.

43.

Rosenstock

I. M.

(1974a). The health belief model and preventive health behavior. Health Education Monographs, 2, 354-386.

44.

Rosenstock

I. M.

(1974b). Historical origins of the health belief model. Health Education Monographs, 2, 328-335.

45.

Russell

R. T.

(2009). Veterans treatment court: A proactive approach. New England Journal on Criminal & Civil Confinement, 35, 357-372.

46.

Substance Abuse and Mental Health Services Administration. (2012). SAMHSA’s working definition of recovery. Retrieved from https://store.samhsa.gov/shin/content/PEP12-RECDEF/PEP12-RECDEF.pdf

47.

Timko

Midboe

A. M.

Maisel

N. C.

Blodgett

J. C.

Asch

S. M.

Rosenthal

Blonigen

D. M.

(2014). Treatments for recidivism risk among justice-involved Veterans. Journal of Offender Rehabilitation, 52, 620-640.

48.

Unified Judicial System of Pennsylvania. (2017). Veterans courts. Retrieved from http://www.pacourts.us/judicial-administration/court-programs/veterans-courts

49.

U.S. Department of Veterans Affairs. (2017). Homeless Veterans: Veterans justice outreach programs. Retrieved from https://www.va.gov/homeless/vjo.asp

50.

Ward

Gannon

T. A.

(2006). Rehabilitation, etiology, and self-regulation: The comprehensive good lives model of treatment for sexual offenders. Aggression and Violent Behavior, 11, 77-94.

51.

Ward

Mann

R. E.

Gannon

T. A.

(2007). The good lives model of offender rehabilitation: Clinical implications. Aggression and Violent Behavior, 12, 87-107.

52.

Ward

Stewart

C. A.

(2003). The treatment of sex offenders: Risk management and good lives. Professional Psychology: Research and Practice, 34, 353-360.

53.

Whitehead

P. R.

Ward

Collie

R. M.

(2007). Time for a change: Applying the Good Lives Model of rehabilitation to a high-risk violent offender. International Journal of Offender Therapy and Comparative Criminology, 51, 578-598.

54.

Yong

A. D.

Williams

M. W. M.

Provan

Clarke

Sinclair

(2015). How do offenders move through the stages of change? Psychology, Crime & Law, 21, 375-397.