Facilitating Treatment Access and Engagement for Justice-Involved Veterans With Substance Use Disorders

Abstract

More than one half of U.S. military Veterans with criminal-justice involvement report problematic substance use, but less than one third ever receive or engage in treatment for substance use disorders (SUDs), despite access to the Veterans Health Administration (VA). This underutilization of services places an already vulnerable population at risk of negative outcomes, such as poor physical and mental health, intimate partner violence, homelessness, suicide, and criminal recidivism. These risks and harms can be reduced through connection with SUD treatment services, and many Veterans already qualify for care through the VA and other agencies. In this review, we outline the known and likely barriers to SUD treatment access and engagement for justice-involved Veterans, suggest policy responses to these barriers, and describe current efforts within the VA and community organizations to address access and engagement in this population. A summary of current knowledge is provided, and directions for future research are suggested.

Keywords

treatment access engagement substance use disorder Veteran criminal justice

Justice-involved Veterans (i.e., former U.S. military personnel who have been detained by, or are under the supervision of, the criminal-justice system) make up approximately 10% of the population of incarcerated U.S. adults (Greenberg & Rosenheck, 2008; Mumola, 2000; Noonan & Mumola, 2007), which amounts to approximately 140,000 Veterans incarcerated in state or federal prisons (Noonan & Mumola, 2007) and 69,300 in local jails (Mumola, 2000). However, these estimates likely represent only a small portion of the total number of justice-involved Veterans, given that approximately 75% of the total U.S. correctional population are on probation or parole in the community rather than incarcerated in prisons or jails (Glaze, 2011).

Substance use disorders (SUDs) are highly prevalent among justice-involved Veterans (Noonan & Mumola, 2007; Tsai, Kasprow, & Rosenheck, 2013). For example, among incarcerated Veterans, 57% in federal prison and 61% in state prison meet criteria for an SUD (Noonan & Mumola, 2007). For Iraq and Afghanistan Veterans who are justice-involved, 56% of their interactions with the criminal-justice system are related to either alcohol or drugs (Rieckhoff, Schleifer, & McCarthy, 2012). Furthermore, as many as two thirds of justice-involved Veterans who are seen by outreach specialists from the Veterans Health Administration (VA) are assessed as having an alcohol or drug use disorder and determined to be in need of SUD treatment (Department of Veterans Affairs, 2012a, 2012b).

Despite the extensive need for SUD treatment among justice-involved Veterans, most never access or engage in these services (Elbogen et al., 2013; Hoge et al., 2004; Milliken, Auchterlonie, & Hoge, 2007). For example, fewer than half of Veterans in jail receive any VA mental-health care the year after being contacted by a VA Outreach Specialist (McGuire, Rosenheck, & Kasprow, 2003), with utilization rates of only 30% for outpatient mental-health services and only 3% for inpatient services. Thus, SUDs are both highly prevalent and undertreated among justice-involved Veterans.

Facilitating justice-involved Veterans’ access to and engagement in SUD treatment is critical for their long-term health and well-being. SUDs are linked to and can exacerbate a host of negative outcomes among justice-involved Veterans, including poor physical and mental health (McGuire et al., 2003; Noonan & Mumola, 2007; Osher, 2005; Saxon et al., 2001; Tsai, Kasprow, & Rosenheck, 2013), intimate partner violence (Fairweather, Gambill, & Tinney, 2010; Weaver, Joseph, Dongon, Fairweather, & Ruzek, 2013), homelessness (Tsai, Rosenheck, Kasprow, & McGuire, 2013), and suicide (Frisman & Griffin-Fennell, 2009; Swords to Plowshares, 2011; Wortzel, Blatchford, Conner, Adler, & Binswanger, 2012), and are one of the strongest predictors of criminal offending among Veterans (Erickson, Rosenheck, Trestman, Ford, & Desai, 2008). Accordingly, increasing justice-involved Veterans’ access to and engagement in SUD treatment can improve these health outcomes and reduce the likelihood of criminal recidivism in this population (Center for Substance Abuse Treatment [CSAT], 2005; Cradock-O’Leary, Young, Yano, Wang, & Lee, 2002; Pandiani, Ochs, & Pomerantz, 2010). Furthermore, SUD treatment services have been shown to be highly cost-effective (Ettner et al., 2006) and may therefore reduce the significant financial burden that justice-involved Veterans pose to the VA and other health care systems (McGuire et al., 2003). Importantly, the endogeneity of other risk factors (e.g., homelessness, poor physical health, mental disorders) within this population suggests that holistic care might promote better management of both SUDs and those other factors.

Using a prevailing model of health care utilization (Andersen & Newman, 2005), the goals of this article are to (a) review known and likely barriers to SUD treatment access and engagement among justice-involved Veterans, (b) suggest possible policy responses to these barriers, and (c) describe current efforts within the VA and community organizations that can improve access and engagement. We hope this document can serve as a guide to clinicians and systems seeking to provide the most effective care for justice-involved Veterans with SUDs, stimulate research, and facilitate treatment engagement among this vulnerable population.

Review Strategy

The current qualitative review was derived from a collaborative project between the Center for Innovation to Implementation at the Veterans Affairs Palo Alto Health Care System and the Veterans Health Administration Justice Programs, which generated an internal structured evidence review regarding the treatment needs of justice-involved Veterans and associated psychological interventions (Blodgett, Fuh, Maisel, & Midboe, 2013). The initial review included a sample of more than 200 articles, derived from multiple search engines (i.e., Google Scholar, PsycInfo, PubMed, and Web of Science) and targeted searches of relevant agencies (e.g., U.S. Bureau of Justice Statistics, U.S. National Institute of Justice, Substance Abuse and Mental Health Services Administration [SAMHSA]’s National GAINS Center, and the U.S. Bureau of Prisons).

The literature about access and engagement for justice-involved Veterans with SUD was sparse, and thus, our review expanded the search to related research areas to identify likely barriers and possible policy responses. These areas included (a) Veterans, (b) SUDs (e.g., “alcohol” / “drug” / “substance”), (c) treatment, and (d) criminal-justice involvement (“justice involve*” / “incarcerat*” / “legal” / “prison” / “jail”). From this list, we further selected articles based on their relevance to access and engagement.

Why Are Justice-Involved Veterans Not Accessing and Engaging in Treatment for SUD?

This section reviews known and likely barriers to SUD treatment access and engagement among justice-involved Veterans. Treatment access refers to appropriate and well-timed care that is affordable to clients and integrated across systems (e.g., Petzel, 2012) and includes outpatient, inpatient, residential, and pharmacotherapy services (Harris, Gifford, Hagedorn, & Ekstrom, 2011). Treatment engagement includes actions that clients take to maximize treatment benefits, including attendance, assessment, group or individual psychotherapy, pharmacotherapy, mutual-help group attendance, or biomarker drug testing (Center for Advancing Health, 2010; Department of Veterans Affairs & Department of Defense [VA/DoD], 2009; Institute of Medicine, 2013). Access and engagement represent two aspects of health-service utilization, which is shaped by both individual and societal influences (Andersen & Newman, 2005).

As an organizing structure, throughout this review, we draw on Andersen and Newman’s (2005) model of determinants of health-service utilization to summarize barriers to and facilitators of SUD treatment among justice-involved Veterans. Specifically, we highlight predisposing factors (i.e., stigma; co-occurring disorders), need (i.e., lack of awareness or ambivalence about the need for SUD treatment), and lack of enabling resources (i.e., competing basic needs; lack of awareness of or ineligibility for services; insufficient treatment, including while incarcerated) that may affect whether or not justice-involved Veterans with SUDs access and engage in treatment for these problems. To guide the reader, Table 1 provides a summary of these barriers to SUD treatment access and engagement, along with possible policy responses, which are reviewed within the second half of this article.

Table 1.

Summary of Barriers to SUD Treatment Access and Engagement Among Justice-Involved Veterans and Possible Policy Responses.

Barrier	Possible policy response
1. Stigma.	1. Address stigma at institutional and individual levels (e.g., psychoeducation, peer-based services, training in “cultural competence”).
2. Co-occurring disorders.	2. Address co-occurring disorders through integrated care (e.g., meeting Veterans within primary care and similar settings).
3. Lack of awareness or ambivalence about the need for SUD treatment.	3. Address lack of awareness or ambivalence through use of motivational strategies (e.g., brief assessments, motivational interviewing, Motivational Enhancement Therapy).
4. Competing basic needs.	4. Address competing needs via case management, flexible interventions, and housing assistance (e.g., adaptive protocols, Internet-based services, telehealth interventions, housing-first models).
5. Lack of awareness of or ineligibility for services.	5. Address lack of awareness of or ineligibility for services by connecting Veterans to peer resources.
6. Insufficient treatment, including while incarcerated.	6. Address insufficient treatment by tailoring SUD care to Veteran needs and bridging criminal-justice and health care systems (e.g., full range of SUD services, innovative evidence-based treatments, Veterans courts, Veterans Justice Programs, Sequential Intercept Model).

Note. SUD = substance use disorder.

Stigma

SUDs and justice involvement both carry significant stigma in U.S. society (Hartwell, 2004). Among justice-involved people, stigma-related labels (e.g., “addict,” “criminal offender,” “ex-con”) may lead individuals to experience social exclusion, and thereby hinder community reintegration (LeBel, 2012; Winnick & Bodkin, 2008).

For justice-involved Veterans with SUDs, yet another layer of social stigma is added due to a military culture that often stigmatizes help seeking for mental health and substance use problems (Gibbs, Olmsted, Brown, & Clinton-Sherrod, 2011; Greene-Shortridge, Britt, & Castro, 2007; McFarling, D’Angelo, Drain, Gibbs, & Olmsted, 2011). Factors such as ideas of weakness, inability to return to work, and loss of rank are cited as barriers to help seeking within the military (Milliken et al., 2007; Vogt, 2011). For example, a survey of active-duty soldiers and Marines found that 65% of respondents who screened positive for a mental disorder believed they would be considered “weak” by their peers for seeking mental-health treatment (including for SUD), 63% believed they would be treated differently by leadership, and 50% believed doing so would harm their career (Hoge et al., 2004). Moreover, perceived public (Vogt, 2011) and self-stigma (Held & Owens, 2013) for seeking help has been found to contribute to negative perceptions of mental health care (Brown, Creel, Engel, Herrell, & Hoge, 2011; Kim, Britt, Klocko, Riviere, & Adler, 2011), and lead to underutilization of mental-health services after separation from the military (Pietrzak, Johnson, Goldstein, Malley, & Southwick, 2009). Consequently, stigma may be a driving factor in the underutilization of SUD treatment among justice-involved Veterans.

Co-Occurring Disorders

Justice-involved Veterans with SUDs are disproportionately affected by a number of co-occurring physical and mental-health problems (Saxon et al., 2001; SAMHSA, n.d.), such as military sexual trauma, traumatic brain injury, posttraumatic stress disorder, and chronic pain. Those Veterans who also have co-occurring mental disorders are at particularly high risk of negative outcomes; however, they are the least likely to seek or engage in services that might help (SAMHSA, n.d.). This trend of underutilization among individuals with comorbid conditions likely applies to Veterans, as well. For example, among Veterans who are homeless and predominantly justice-involved, rates of multi-morbid physical and mental-health disorders and SUDs have been calculated at 29%; however, only one third of these individuals reported utilizing VA care (M. Cunningham, 2009). Not surprisingly, co-occurring disorders and related circumstances (e.g., homelessness) exacerbate competing basic needs and complicate accessing and engaging in treatment (McGuire, 2007; SAMHSA, 1998). As in the general population, subsections of justice-involved Veterans are likely to require additional care for co-occurring concerns based on demographic factors (e.g., age-related health or psychiatric disorders, reproductive concerns).

Lack of Awareness or Ambivalence About the Need for SUD Treatment

Like most people who misuse substances, justice-involved Veterans with SUD might not perceive their use as requiring formal intervention. For example, a large U.S. survey found that only one in nine adults with problematic alcohol use perceived a need for SUD treatment, and this was a key barrier to accessing treatment (Edlund, Booth, & Feldman, 2009). Similarly, in a study of recent Veterans with an “invisible injury” (i.e., mental-health concern), 66% did not perceive a need for mental health care, including SUD treatment (Rieckhoff et al., 2012). Ambivalence—perceiving both benefits and drawbacks of change or of treatment—is also common among people with SUD, including justice-involved individuals (M. D. Clark, Walters, Gingerich, & Meltzer, 2006) and Veterans (Oser, McKellar, Moos, & Moos, 2010). Accordingly, a lack of awareness of or ambivalence about the need for SUD treatment might serve as a key barrier to access and engagement in these services for justice-involved Veterans.

Competing Basic Needs

Justice-involved Veterans who reintegrate after incarceration typically face many immediate needs that might interfere with seeking treatment for SUD, including finding housing, seeking employment, managing families and households, and handling legal problems (Mallik-Kane & Visher, 2008). They may also face practical barriers to attending treatment, such as lack of suitable child care, unreliable transportation, no local VA, insufficient time off work, and unaffordable cost if not receiving service-connected care within VA (Elbogen et al., 2013; Ouimette et al., 2011; Rieckhoff et al., 2012). Indeed, Veterans report that such barriers are among the most important factors that affect their likelihood of accessing treatment services (Rieckhoff et al., 2012).

Perhaps the most critical practical barrier for justice-involved Veterans with SUDs is homelessness. In a national sample of 30,348 incarcerated Veterans, VA researchers observed a rate of homelessness 5 times greater than in the general population, and noted that justice-involved Veterans with SUD often struggle with obtaining and maintaining stable housing (Legal Action Center, 2009; Roman & Travis, 2004; Tsai, Rosenheck et al., 2013). In addition, given that justice-involved individuals who are homeless have high rates of co-occurring disorders (McNiel, Binder, & Robinson, 2005; SAMHSA, 1998), it is conceivable that Veterans with these overlapping challenges find it difficult to prioritize SUD treatment.

Lack of Awareness of or Ineligibility for Services

Many Veterans likely would benefit from access to SUD treatment services, but are either unaware they are eligible for these services or unsure whether such services would be appropriate for them (Elbogen et al., 2013; National Association of State Alcohol and Drug Abuse Directors, 2009). For example, one survey showed that only 34% of Veterans surveyed reported understanding their VA health care benefits. Within that report, variations in knowledge existed based on enrollment status, race, ethnicity, sex, and service era (Department of Veterans Affairs, 2010), which also reflects the growing heterogeneity of the Veteran population and the variety of efforts that might be required to reach them. Furthermore, approximately 20% of Veterans are ineligible for VA services due to a “less than honorable” military discharge (Noonan & Mumola, 2007), which means they might need to seek community-or peer-based services instead.

Insufficient Treatment, Including While Incarcerated

Although many justice-involved Veterans with SUDs have a history of receiving professional treatment or participating in other programs such as self-help groups or substance education (Karberg & James, 2005), rates of formal treatment while incarcerated are low (Re-Entry Policy Council, 2005; Rosenthal & McGuire, 2013). For example, among jail inmates with a current SUD diagnosis, 63% had participated in an SUD treatment or a program at some point in the past; however, only 19% had participated since admission (Karberg & James, 2005).

Behavioral and medical treatment options for SUD (e.g., medically supervised withdrawal [“detox”], opiate replacement, cravings medications) within correctional settings can be severely limited or unavailable (CSAT, 2005). When treatment is available, it is not necessarily appropriate or sufficient. For example, it has been estimated that less than 60% of SUD treatment provided to justice-involved individuals in incarcerated settings constitutes evidence-based practice (Friedmann, Taxman, & Henderson, 2007). Furthermore, Veterans are unable to seek alternate care prior to release: Under Federal regulation 38 CFR § 1738(c)(5), health care (including SUD treatment) must be provided by correctional institutions while Veterans are incarcerated, and not by VA or other institutions. That means care necessarily must be transferred on re-entry to the community, and poor coordination of SUD resources on release can interfere with further treatment or aftercare, and therefore with maintaining gains (e.g., Schwartz & Levitas, 2011).

Also, importantly, a single episode of treatment is not always sufficient for “curing” SUDs. Although many people who meet diagnostic criteria for SUDs do experience remission—with or without SUD treatment (e.g., J. A. Cunningham & McCambridge, 2011)—others experience them as a “chronic, relapsing condition” and require multiple episodes of care (McLellan, Lewis, O’Brien, & Kleber, 2000). Thus, many justice-involved Veterans who receive an initial episode of treatment, even while incarcerated, will likely require additional treatment on re-entry and throughout their lifetimes.

Suggested Strategies for Improving Access and Engagement

Given the aforementioned barriers for justice-involved Veterans to accessing and engaging in SUD treatment, a multi-pronged approach is clearly required to address this complex issue. Researchers, clinicians, and policy makers have begun to develop practices aimed at increasing that group’s participation in treatment, but many questions remain. For example, if extant theories are correct, further research could help identify candidate programs and evaluate them for efficacy and effectiveness, although few data are available at present. Alternatively, even in the presence of correct theories, insufficient access and engagement could be due to unsuccessful funding and implementation of sound policies. Our article seeks to suggest some possible strategies for improving access and engagement, and stimulate discussion about policy considerations.

This section outlines some strategies for improving access and engagement in SUD treatment by addressing (a) stigma at institutional and individual levels, (b) co-occurring disorders through integrated care, (c) lack of awareness or ambivalence through motivational strategies, (d) competing needs via case management, flexible interventions, and housing assistance, (e) lack of awareness of or ineligibility for services by connecting Veterans to peer resources, and (f) insufficient treatment, including while incarcerated, by bridging criminal-justice and health care systems (see Table 1).

Address Stigma at Institutional and Individual Levels

Some approaches worth consideration for addressing stigma among Veterans (e.g., Dickstein, Vogt, Handa, & Litz, 2010; Marmar, 2009; Pietrzak et al., 2009) include challenging self-stigma with cognitive re-framing or mindfulness (Lillis, Hayes, Bunting, & Masuda, 2009; Stecker & Fortney, 2011), ensuring confidentiality, offering psychoeducation about the nature and effectiveness of mental health treatments, and having in-person or video contact with other military members or Veterans recovering from SUD (e.g., http://www.maketheconnection.net/; Department of Veterans Affairs, 2013). Determining the effectiveness of these methods in reducing stigma or promoting help seeking among justice-involved Veterans with SUDs and discovering how to implement such interventions at different stages of justice involvement are key areas for future research and program development.

Although we suggest that the military and Veteran culture may be associated with barriers for Veterans with SUDs seeking and engaging in professional help, Veteran status also could potentially facilitate help seeking. Justice-involved Veterans with SUDs often have access to peer-to-peer services, Vet Centers, and 12-step groups comprised solely of Veterans (e.g., Department of Veterans Affairs, 2013). Greater privacy through technological advances might also reduce Veterans’ contact with stigmatizing situations (Lapham et al., 2012); examples include computer-delivered screening, assessment, and interventions, mobile-phone “apps” (National Center for Posttraumatic Stress Disorder, 2013), and online access to medical records and secure messaging with providers through My HealtheVet (VA, 2013).

In addition, providers who frequently work with justice-involved Veterans with SUDs might play a role in reducing stigma for these patients. Addressing the “cultural competency” of providers in terms of their understanding of Veteran and criminal-justice issues may enhance client–provider relationships and ultimately improve engagement (Swords to Plowshares, 2011). Examples of steps to address this issue may include diversity trainings or provider self-education; use of inclusive and non-stigmatizing language with other providers, Veterans, and Veterans’ families; adopting a strengths-based approach; inviting Veterans to adopt a leadership role in group interventions; asking patients about their experiences of stigma and their relation to current SUD treatment; and practicing mindfulness surrounding negative impressions of SUD and substance-using clients (Byrne, 2000; Penn & Couture, 2002; SAMHSA, 2006; Thornicroft, Brohan, Kassam, & Lewis-Holmes, 2008).

To the best of our knowledge, these approaches have not been systematically studied with justice-involved Veterans to evaluate efficacy, efficiency, or comparative merit. Focused investigations of specific programs and cost–benefit analyses could help determine their appropriateness for addressing stigma within justice-involved Veterans. Although stigma exists at a societal level and not solely within SUD treatment settings, key decision makers might help provide leadership in evaluating stigma as a possible barrier to care and prioritizing research and possible policy changes to support inclusion and treatment access.

Address Co-Occurring Disorders Through Integrated Care

Because many justice-involved Veterans with co-occurring disorders face challenges related to a lack of access to integrated care (Osher, 2008), another goal is to provide coordinated care by meeting them in settings where they present for health care services (e.g., primary care; Tsan, Zeber, Stock, Sun, & Copeland, 2012). Although findings are mixed about whether SUDs are best treated in primary care or in specialty care (e.g., Saxon et al., 2006), there appear to be few downsides in terms of SUD treatment outcomes and several advantages to engagement when SUD services are integrated into primary-care settings, primary-care services are integrated into SUD settings, or SUD and other mental health care are provided concurrently (Foa et al., 2013; Saxon et al., 2006). Coordinated care might also improve Veterans’ retention in care and increase the likelihood of sustained care for SUD services following intensive treatment (Schaefer, Ingudomnukul, Harris, & Cronkite, 2005).

Address Lack of Awareness or Ambivalence Through Motivational Strategies

A range of strategies related to the assessment and enhancement of motivation might address the barrier of unawareness or ambivalence about the need for SUD treatment. These include brief screening of needs and readiness, inquiring about Veterans’ current motivation for seeking care, and use of motivational interviewing if Veterans are ambivalent about treatment. Given that SUDs are often chronic (i.e., 40% of Veterans re-entered treatment within 2 years of an initial SUD episode; Hawkins, Grossbard, Benbow, Nacev, & Kivlahan, 2012), readiness is likely to wax and wane, and engagement might be best conceptualized as a cyclical process that requires ongoing monitoring.

Brief screening for Veteran readiness and motivation for SUD treatment can help providers determine how prepared the Veteran feels to enter treatment and what factors might influence that decision. Although readiness and motivation can be assessed with a variety of well-validated instruments, the Circumstances, Motivation, Readiness, and Suitability Scale (CMRS; Leon, Melnick, Kressel, & Jainchill, 1994) and Treatment Readiness Questionnaire (TRQ; Casey, Day, Howells, & Ward, 2007; McMurran & Ward, 2010; Ward, Day, Howells, & Birgden, 2004) were developed specifically for justice-involved adults with SUD, and the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES; Miller & Tonigan, 1996) has been validated with that demographic (Peters, Bartoi, & Sherman, 2008). Therefore, these measures may be preferable for formally assessing readiness and motivation for treatment with justice-involved Veterans. In addition, given the limited time and resources of most providers, informal assessment through interview or the “readiness ruler” (Heather, Smailes, & Cassidy, 2008) may have considerable practical utility for quickly screening readiness and motivation for treatment. The Alcohol Use Disorders Identification Test–Consumption (AUDIT-C; Bush, Kivlahan, McDonnell, Fihn, & Bradley, 1998) also predicts readiness for SUD treatment in Veterans (Krenek, Maisto, Funderburk, & Drayer, 2011; Williams et al., 2006), and that measure already has been universally used in VA primary care, which makes its use particularly efficient in that setting.

A prominent strategy for addressing ambivalence about SUD treatment is the use of motivational interviewing (MI). MI is a “person-centered counseling style for addressing the common problem of ambivalence about change” (Miller & Rollnick, 2013, p. 29), and an evidence-based approach to SUD treatment (CSAT, 1999; National Registry of Evidence-based Programs and Practices, 2007; VA/DoD, 2009). Similarly, Motivational Enhancement Therapy (MET; Miller, Zweben, DiClemente, & Rychtarik, 1994) uses the client-centered style of MI along with personalized normative feedback to develop discrepancy about substance use in Veterans who are drinking or using substances outside recommended guidelines and to increase the Veteran’s perceived importance of changing substance use and possibly entering treatment. A robust literature supports MI and MET for increasing client motivation to engage in treatment, including for Veterans with SUD (e.g., Bogue & Nandi, 2012; Davis, Baer, Saxon, & Kivlahan, 2003; McMurran, 2009; Seal et al., 2012; Wain et al., 2011). Two randomized trials have specifically targeted treatment engagement for justice-involved Veterans: Davis and colleagues (2003) found that use of MI plus feedback was associated with increased access of VA SUD care after jail release, and Wain and colleagues (2011) found that an MI-based interview was more effective than a control condition in engaging Veterans in a VA SUD–homelessness residential treatment program.

Consistent use of MI and MET with justice-involved Veterans who are ambivalent about changing substance use or entering SUD treatment can be an important step in maximizing opportunities for access and engagement. Such motivational strategies, however, may need to be adapted for the unique needs and circumstances of this population. For example, drawn from a tailored training for Health Care Re-Entry Veterans staff, recommendations for working with justice-involved Veterans with SUD include use of open-ended questions that emphasize past successes and barriers on prison re-entry, asking Veterans to personalize strategies for preventing relapse, linking substance use to health concerns, and brainstorming “early warning signs” of SUD-related problems (Baer & Kivlahan, 2008). Furthermore, brief forms of MI are especially needed in incarcerated settings where the time allotted for outreach specialists to conduct assessment and treatment is likely to be limited.

Address Competing Needs Via Case Management, Flexible Interventions, and Housing Assistance

Intensive case management, use of flexible interventions, and housing assistance might help address many of the competing needs that likely hinder justice-involved Veterans’ engagement in SUD treatment. Case management is considered an evidence-based treatment for SUD that is particularly helpful for people who are homeless or have co-occurring mental health problems—issues that are highly prevalent among justice-involved Veterans (Alexander, Nahra, Lemak, Pollack, & Campbell, 2008; CSAT, 1998; Vanderplasschen, Wolf, Rapp, & Broekart, 2007). Case managers can connect justice-involved Veterans with tangible community and VA resources, such as travel pay, housing assistance, food stamps, employee assistance programs, child care, or temporary disability compensation, to combat practical barriers that might otherwise prevent attendance at SUD treatment.

These competing needs might also be addressed by providing flexibly delivered interventions, such as telehealth interventions for rural Veterans (e.g., 39% of Operation Enduring Freedom/Operation Iraqi Freedom Veterans receiving VA care; Smee et al., 2013), evening or weekend clinics, family friendly interventions and facilities, and a variety of treatment modalities (e.g., brief interventions, 12-step meetings, longer but less frequent appointments). Such approaches have been successfully adapted for justice-involved individuals with SUD and mental-health concerns (e.g., Osher & Steadman, 2007), and are likely to apply to Veterans. Notably, such flexible interventions might also help address other key barriers to SUD treatment access and engagement in this population such as stigma and co-occurring disorders.

Adaptive continuing care strategies could be helpful for dealing with the range of needs encountered by those working with justice-involved Veterans. Such adaptive protocols entail a flexible approach to treatment by using regular assessments of progress to inform changes in a treatment plan—for example, by adding psychotherapy sessions to address motivation or engagement, increasing treatment intensity if a lapse to substance use has occurred, or transitioning into lower intensity telephone monitoring after a successful intervention (McKay, 2009). Well-executed adaptive care might potentially result in long-term, cost-effective benefits by accurately targeting specific resources to those at specific points in their recovery (L. M. Collins, Murphy, & Bierman, 2004). This type of treatment requires the use of assessment instruments that can capture changes over time for variables related to outcomes of interest. Adaptive protocols could potentially be developed for justice-involved Veterans, in which “decision rules” inform treatment changes based on assessment values for “tailoring variables” (e.g., an above-threshold score on an assessment for risk of relapse could trigger a shift to more intensive treatment; McKay, 2009, p. 168). However, those protocols would need to be developed and validated through research.

Because homelessness is associated with such severe negative outcomes for justice-involved Veterans with SUD, reducing it holds the potential to mitigate some of those effects and simultaneously increase the likelihood of engagement in SUD treatment. One path to reducing Veteran homelessness has been VA benefits (e.g., Veterans Affairs Office of Public and Intergovernmental Affairs, 2013). Those include vocational rehabilitation, education, housing, and other important services (Veterans Benefits Administration, 2014), as well as financial compensation for medical or psychological injuries obtained or exacerbated in the course of military services (Edens, Kasprow, Tsai, & Rosenheck, 2011). Community organizations, Vet Centers, and VA providers can assist justice-involved Veterans in applying for benefits they might be eligible to receive, which can allow struggling Veterans to achieve greater financial stability. In turn, greater stability might facilitate Veterans’ engagement in health care services, such as SUD treatment.

Employing housing-first models may also be an innovative approach to solving homelessness among justice-involved Veterans, and in turn to improving SUD treatment access and engagement. In traditional SUD treatment, as opposed to “housing-first” models, abstinence is required on beginning SUD treatment. However, in such programs, most participants are not retained in treatment and as few as a quarter complete it (Caton, Wilkins, & Anderson, 2007). By contrast, harm-reduction models view SUD as a chronic condition that sometimes involves lapses in abstinence. In this vein, housing-first programs have gained in popularity as a method to house homeless substance users—even if they have not achieved sobriety—to prevent other harms to individuals and society (Montgomery, Hill, Kane, & Culhane, 2013; Tsai, Kasprow, & Rosenheck, 2013). Housing-first programs also promote stability, accountability, self-sufficiency, and quality of life, which might provide additional resources to manage SUD and related concerns, and ultimately improve client functioning and reduce societal costs (e.g., Tsemberis, Gulcur, & Nakae, 2004). Those programs are relatively new and are still being evaluated; however, initial studies have shown comparable results with traditional SUD treatment, but with improved retention and greatly reduced times to accessing services (Caton et al., 2007; Tsemberis et al., 2004). Similarly, there is research support for the effectiveness of “supported housing,” or SUD treatment that provides housing for homeless treatment participants, typically without being contingent on sobriety (Rog, 2004), as well as for case management with a housing focus to improve SUD treatment engagement (Winn et al., 2013). Such programs have been shown to provide significant savings to social systems, due to decreased utilization of emergency medical services and greater treatment attendance (S. E. Collins et al., 2012; Kraybill & Zerger, 2003; Larimer et al., 2009).

Address Lack of Awareness of or Ineligibility for Services by Connecting Veterans to Peer Resources

Peer-based support is important for justice-involved Veterans (Resnick & Rosenheck, 2008; Rosenthal & McGuire, 2013) and may be of particular value to justice-involved Veterans who are unaware of or ineligible for VA services. Peer mentorship provides many benefits, including improved SUD and related outcomes (e.g., Mentorship for Addictions Problems to Enhance Engagement to Treatment; Tracy, Burton, Nich, & Rounsaville, 2011) and increased feelings of empowerment (Resnick & Rosenheck, 2008). In addition, in a large survey of active-duty personnel and recent Veterans (Rieckhoff et al., 2012), 90% reported that peer-support groups were at least “somewhat important” in providing for mental-health needs for Veterans, which suggests that the sense of military camaraderie fostered there helps address those concerns. For Veterans in prison or jail, peer-support groups could also be an important source of information about available community and VA treatment services for developing a re-entry plan as an individual’s date of release nears (Rosenthal & McGuire, 2013).

An example of incorporating peer-based support for incarcerated Veterans in jail is the Community of Veterans Engaged in Restoration (COVER) program, which includes elements of restorative justice, treatment, service-linkage and re-entry services (Schwartz & Levitas, 2011). Furthermore, peer support has also been included as a formal element of Veterans treatment courts in the form of Veteran mentors in the community who provide encouragement and a positive example for justice-involved Veterans as they work through their treatment programs and other court-ordered requirements (Moore, 2012). Similarly, because Veterans of different service eras might have unique needs based on their military experiences and demographics, it will be important to assess whether general peer-support services are sufficient or whether tailoring peer services might help provide an even better fit.

Address Insufficient Treatment by Tailoring SUD Care to Veteran Needs and Bridging Criminal-Justice and Health Care Systems

For many justice-involved Veterans, SUD is often a chronic condition involving numerous relapses and multiple treatment episodes. This section addresses how SUD services might be tailored to the treatment needs of justice-involved Veterans to promote engagement, and suggests ways to bridge the criminal-justice and health care systems to increase access to SUD care during and after incarceration.

A continuum of SUD severity exists within Veterans, and different levels of severity are believed to warrant differential engagement responses (VA/DoD, 2009). Offering a full range of treatment options to meet the needs of justice-involved Veterans with different severities of SUD might help increase engagement. Veterans with milder SUD might benefit most from the implementation of primary-care screening, focused universal-prevention strategies, or targeted brief interventions, instead of a full course of traditional SUD treatment. For justice-involved Veterans whose SUDs are severe, conceptualizing those disorders as chronic and relapsing might offer a more helpful model to guide intervention, and ongoing efforts toward re-engagement and intervention are viewed as an important aspect of appropriate patient care. For example, innovating new harm-reduction strategies, as has been done successfully with housing-first models, might offer alternatives to abstinence-based models for the treatment of severe SUD. Nonetheless, the benefit of these alternative approaches and their implications for service provision for justice-involved Veterans are ongoing points of debate, which require further research and inquiry.

From a policy standpoint, the development of new evidence-based strategies for engagement and treatment of clients with complex concerns could also benefit justice-involved Veterans. Research on mechanisms of behavior change and active ingredients of efficacious treatments for SUD is underway to improve the efficacy and efficiency of SUD treatment and identify important moderators of outcomes (Department of Health and Human Services, 2013). Better strategies for both treatment engagement and treatment itself might help tailor treatment to specific groups and prevent the need for future episodes of care.

Addressing insufficient treatment while Veterans are incarcerated is complicated and requires coordination among many resources and education for staff across the criminal-justice and health care systems (VA, 2011; Weaver et al., 2013). Meeting justice-involved Veterans where they encounter the criminal-justice system allows for important points of contact between Veterans and Veteran-responsive services (S. Clark, Blue-Howells, Rosenthal, & McGuire, 2010; Drug Policy Alliance, 2009; McGuire et al., 2003; Rosenthal & McGuire, 2013; Wong et al., 2013). In reaction to this need, the VA and coordinating agencies have developed several initiatives, referred to collectively as the Veterans Justice Programs (VJP; Rosenthal & McGuire, 2013), which provide formal links between the justice system and the VA. Importantly, these programs are intended to connect justice-involved Veterans to VA services; however, the design and overarching goals of these programs may serve as a useful model for non-VA agencies that frequently service justice-involved Veterans.

The VJP includes both the Veterans Justice Outreach (VJO) program, which seeks to avoid unnecessary criminalization of Veterans with mental-health concerns through direct community outreach, and the Health Care for Re-Entry Veterans (HCRV) program, which addresses the re-entry needs (e.g., medical, psychiatric, psychosocial) of incarcerated Veterans. These programs utilize a Sequential Intercept Model, which seeks to intervene with justice-involved Veterans at five levels: law enforcement or emergency services, detention or court, jail, re-entry, and the community to facilitate referral and linkage of justice-involved Veterans to needed services (Blue-Howells, Clark, van den Berk-Clark, & McGuire, 2013; Weaver et al., 2013). This model has shown some effectiveness in linking Veterans with VA SUD treatment and other health care (McGuire et al., 2003). Specifically, those authors noted that periods of incarceration typically correspond to periods of abstinence or reduced substance use, which may help facilitate opportunistic connections to SUD treatment resources within the VA and the community (see also Wong et al., 2013).

In addition to linkage services such as the VJP and other community-based programs, Veteran treatment courts offer mental-health treatment in lieu of standard criminal prosecution and can also help to facilitate justice-involved Veterans’ access and engagement in SUD treatment (Little, 2006). In this context, these courts have been developed and expanded to meet the diverse needs of justice-involved Veterans with SUDs and other co-occurring disorders (Christy, Clark, Frei, & Rynearson-Moody, 2012; S. Clark, McGuire, & Blue-Howells, 2010; Russell, 2009; Smee et al., 2013). Those courts include standard treatment-court elements such as regular judicial review, a multi-disciplinary team, and close monitoring of progress. They are particularly conducive to linking justice-involved Veterans to appropriate and available VA services because they typically include VA staff (including VJP outreach specialists) and peer support as part of the court team (National Association of Drug Court Professionals, 2010). The benefits of this coordination between the justice and health care systems notwithstanding, other challenges emerge when these systems interface. For example, recommendations for use of harm-reduction strategies and pharmacotherapy by VA staff may need to be negotiated early on, particularly with judicial staff who are less familiar with these evidence-based approaches to SUD treatment. In addition, the expectations regarding the frequency and length of diversion treatment progress reports and assessments must be established at the outset to ensure that the court’s requirements can be met by the health care system. Also, eligibility requirements for Veteran courts vary by jurisdictions but sometimes are stringent (e.g., combat status, VA eligibility, severity of charge, mental-health diagnosis, willingness to plead “guilty”; S. Clark, McGuire, & Blue-Howells, 2010), which theoretically excludes some Veterans who might benefit. Although the impact so far has been described as relatively minimal (McGuire, Clark, Blue-Howells, & Coe, 2013), ongoing investigation of this issue might be warranted. Finally, a recent study of general mental-health courts found that they were not cost-effective, in part because people with co-occurring SUDs had greater unique needs and higher costs for care (Steadman et al., 2014). Further evaluation of Veterans courts specifically might clarify whether the contextual care in that specialized setting improves cost efficiency or other factors related to client or societal well-being.

Despite the relative newness of Veterans courts, studies have shown preliminary evidence of their efficacy in improving SUD outcomes (Cavanaugh, 2011; S. Clark, McGuire, & Blue-Howells, 2010; Rieckhoff et al., 2012; Russell, 2009; Smee et al., 2013), which makes them a specialized and potentially valuable resource for justice-involved Veterans. Additional steps to ensure that high-quality and evidence-based treatments are being delivered to Veterans through Veterans courts might include that (a) all Veterans with SUD be mandated to attend SUD treatment, which has been shown to increase treatment-completion rates tenfold in justice-involved populations (Coviello et al., 2013), (b) judges collaborate with treatment professionals to make recommendations about elements of treatment and duration, based on evidence-based practices and assessment of the individual needs of the justice-involved client (e.g., Drug Policy Alliance, 2009), (c) correctional facilities be equipped to provide effective SUD treatment to any incarcerated people who need it (e.g., Re-Entry Policy Council, 2005), and (d) policy makers encourage communities with large Veteran populations to begin Veterans courts, support the expansion of outreach efforts, or adjust eligibility requirements to promote greater inclusion. These steps to consider client and systemic needs might improve access to evidence-based SUD programs, which holds the potential to improve not only the quality of care and the likelihood of positive outcomes, but also Veteran satisfaction and investment in ongoing SUD care.

Conclusion

Justice-involved Veterans with SUDs represent a heterogeneous and vulnerable population with many unmet treatment needs and numerous barriers to access and engagement. They also remain a relatively understudied population, and as such, these suggested responses to barriers are offered from the few studies that exist and by triangulation from the related literature on Veterans, justice-involved adults, and people with SUD. Accordingly, a key direction for future research will be to more directly examine which of the aforementioned barriers (and possibly others) are most salient, and which policy responses might be best suited for justice-involved Veterans. Clearly, in such an emerging field, the integration of research and practice is essential. In particular, future research should test whether existing evidence-based programs for criminal-justice populations are similarly effective with justice-involved Veterans and whether adaptations are necessary for this group, or even subgroups of justice-involved Veterans (e.g., recent returnees from Iraq and Afghanistan, women Veterans, Veterans of different racial/ethnic identities and sexual orientations). The importance of this future work notwithstanding, systems such as the VA that serve justice-involved Veterans strive to offer solutions and high-quality, evidence-based clinical care. With increased research and coordinated efforts with other community agencies, the field can continue to progress toward reducing the vulnerability of justice-involved Veterans with SUDs, facilitating steps down the road to recovery.

Footnotes

Acknowledgements

The authors thank the Veterans Health Administration Homeless Programs Office, including Dr. Joel Rosenthal, whose team originated the structured evidence review, an internal document that formed the basis of the current research question and literature review; they also thank Ms. Leena Bui for her assistance in preparing this article.

Authors’ Note

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the U.S. government.

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: This material is the result of work supported with resources and the use of facilities at the Veterans Affairs Palo Alto and Puget Sound Health Care Systems. The authors acknowledge their sources of support: VA Office of Academic Affiliations Advanced Fellowship in Health Services Research and Development (HSR&D) and a Career Development Award (CDA 13-279 to Dr. Finlay), Office of Research and Development, Clinical Sciences (CDA-2 to Dr. Blonigen), and Health Services Research (Research Career Scientist 00-001 to Dr. Timko).

Author Biographies

Lisa H. Glynn, PhD, is a psychology fellow at the Veterans Affairs (VA) Puget Sound Health Care System’s Center of Excellence in Substance Abuse Treatment and Education (CESATE) in Seattle, WA. She develops evidence-based programs and provides direct clinical care to Veterans with substance use disorders. Her research includes exploration of the hypothesized active ingredients of motivational interviewing.

Matthew S. Kendra, PhD, is clinical faculty at Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences. He researches and publishes on stigma, help-seeking, access to mental health services, and substance use. His clinical practice focuses on substance use disorders and dual diagnosis.

Christine Timko, PhD, is a senior research career scientist in the Department of Veterans Affairs (VA) Health Services Research and Development Service. She is also an investigator in the Center for Innovation to Implementation, VA Palo Alto Health Care System, and consulting professor, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine. Dr. Timko’s research focuses on improving patient outcomes by facilitating health care transitions, such as from inpatient or residential treatment to continuing outpatient treatment and participation in mutual-help groups.

Andrea K. Finlay, PhD, is a core investigator at the Center for Innovation at the VA Palo Alto Health Care System, a Career Development Award-2 recipient in VA Health Services Research & Development, and an implementation research coordinator-in-training for the VA Substance Use Disorder Quality Enhancement Research Initiative. Her research focuses on justice-involved Veterans with mental health or substance use disorders, with an emphasis on identifying and addressing gaps in access and engagement in mental health or substance use disorder treatment.

Janet C. Blodgett, MSc, is a researcher at the Center for Innovation to Implementation and Stanford University School of Medicine. Her research interests include treatments for substance use disorders and interventions for justice-involved adults.

Natalya C. Maisel, PhD, is a research health science specialist at the VA Palo Alto Health Care System, Department of Veterans Affairs. Her research interests include mental health care, substance use disorder treatment, and women’s comprehensive primary care.

Amanda M. Midboe is a research scientist at the VA Palo Alto Health Care System’s Center for Innovation to Implementation (Ci2i). Her research includes a focus on mental health and employment needs of Veterans involved in the justice system.

James F. McGuire is a recently retired social welfare researcher and administrator at the VA’s Veterans Health Administration (VHA) homeless programs, where he conducted a number of longitudinal studies of primary care, homeless, and outreach services designed to improve outcomes for homeless and justice-involved Veterans, with numerous peer-reviewed publications related to these areas. For the last 10 years of his work in VA, Dr. McGuire served as the national director of VHA’s justice programs responsible for direction of VHA’s prison re-entry and court/law enforcement-based initiatives for homeless/justice-involved veterans.

Daniel M. Blonigen is a career development awardee (Clinical Science R&D) at the Center for Innovation to Implementation, VA Palo Alto Health Care System. His program of research focuses on assessment and engagement in care among individuals with substance use and co-occurring psychiatric disorders, with a special focus on populations marked by involvement in the criminal justice system.

References

Alexander

J. A.

Nahra

T. A.

Lemak

C. H.

Pollack

Campbell

C. I.

(2008). Tailored treatment in the outpatient substance abuse treatment sector: 1995-2005. Journal of Substance Abuse Treatment, 34, 282-292.

Andersen

Newman

J. F.

(2005). Societal and individual determinants of medical care utilization in the United States. Milbank Quarterly, 83(4), 1-28. doi:10.1111/j.1468-0009.2005.00428.x

Baer

J. S.

Kivlahan

D. R.

(2008, July). Motivational Interviewing (MI) cheat sheet and adaptations for reentry Veterans. Presented at Brief Motivational Interventions for Re-entry Veterans. Seattle, WA.

Blodgett

J. C.

Fuh

I. L.

Maisel

N. C.

Midboe

A. M.

(2013). A structured evidence review to identify treatments needs of justice-involved veterans and associated psychological interventions. Unpublished manuscript. Menlo Park, CA: Center for Health Care Evaluation, VA Palo Alto Health Care System.

Blue-Howells

J. H.

Clark

S. C.

van den Berk-Clark

McGuire

J. F.

(2013). The US department of Veterans Affairs Veterans Justice Programs and the sequential intercept model: Case examples in national dissemination of intervention for justice-involved veterans. Psychological Services, 10, 48-53.

Bogue

Nandi

(2012). Motivational interviewing in corrections: A comprehensive guide to implementing MI in corrections. Retrieved from http://static.nicic.gov/Library/025556.pdf

Brown

M. C.

Creel

A. H.

Engel

C. C.

Herrell

R. K.

Hoge

C. W.

(2011). Factors associated with interest in receiving help for mental health problems in combat veterans returning from deployment to Iraq. The Journal of Nervous and Mental Disease, 199, 797-801.

Bush

K. R.

Kivlahan

D. R.

McDonnell

M. B.

Fihn

S. D.

Bradley

K. A.

(1998). The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking: Ambulatory Care Quality Improvement Project (ACQUIP): Alcohol Use Disorders Identification Test. Archives of Internal Medicine, 158, 1789-1795.

Byrne

(2000). Stigma of mental illness and ways of diminishing it. Advances in Psychiatric Treatment, 6, 65-72.

10.

Casey

Day

Howells

Ward

(2007). Assessing suitability for offender rehabilitation: Development and validation of the Treatment Readiness Questionnaire. Criminal Justice and Behavior, 34, 1427-1440.

11.

Caton

C. L.

Wilkins

Anderson

(2007, March). People who experience long-term homelessness: Characteristics and interventions. Paper presented at the 2007 National Symposium on Homelessness Research, Washington, DC: National Symposium on Homelessness Research. Retrieved from http://aspe.hhs.gov/hsp/homelessness/symposium07/caton/

12.

Cavanaugh

J. M.

(2011). Helping those who serve: Veterans treatment courts foster rehabilitation and reduce recidivism for offending combat veterans. New England Law Review, 45, 463-487.

13.

Center for Advancing Health. (2010). A new definition of patient engagement: What is engagement and why is it important? Washington, DC: Center for Advancing Health. Retrieved from http://www.cfah.org/file/CFAH_Engagement_Behavior_Framework_current.pdf

14.

Center for Substance Abuse Treatment. (1998). Comprehensive case management for substance abuse treatment (Treatment Improvement Protocol Series 27). Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://adaiclearinghouse.org/downloads/TIP-35-Enhancing-Motivation-for-Change-in-Substance-Abuse-Treatment-59.pdf

15.

Center for Substance Abuse Treatment. (1999). Enhancing motivation for change in substance abuse treatment (Treatment Improvement Protocol Series 35). Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK64967/pdf/TOC.pdf

16.

Center for Substance Abuse Treatment. (2005). Substance abuse treatment for adults in the Criminal Justice System Treatment Improvement Protocol (TIP) (Series No. 44. DHHS Publication No. (SMA) 05-4056). Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK64137/pdf/TOC.pdf

17.

Christy

Clark

Frei

Rynearson-Moody

(2012). Challenges of diverting veterans to trauma informed care: The heterogeneity of Intercept 2. Criminal Justice and Behavior, 39, 461-474.

18.

Clark

M. D.

Walters

S. T.

Gingerich

Meltzer

(2006). Motivational interviewing for probation officers: Tipping the balance toward change. Federal Probation, 70(1), 38-44.

19.

Clark

Blue-Howells

Rosenthal

McGuire

(2010). 10NC1 homeless program VJO strategic plan, FY 2012-2016. Washington, DC: Department of Veterans Affairs.

20.

Clark

McGuire

Blue-Howells

(2010). Development of veterans treatment courts: Local and legislative initiatives. Drug Court Review, 7, 171-208.

21.

Collins

L. M.

Murphy

S. A.

Bierman

K. L.

(2004). A conceptual framework for adaptive preventive interventions. Prevention Science, 5, 185-196.

22.

Collins

S. E.

Malone

Clifasefi

Ginzler

J. A.

Garner

M. D.

Burlingham

. . .Larimer

M. E.

(2012). Project-based housing first for chronically homeless individuals with alcohol problems: Within-subjects analyses of two-year alcohol-use trajectories. American Journal of Public Health, 102, 511-519.

23.

Coviello

D. M.

Zanis

D. A.

Wesnoski

S. A.

Palman

Gur

Lynch

K. G.

McKay

J. R.

(2013). Does mandating offenders to treatment improve completion rates? Journal of Substance Abuse Treatment, 44, 417-425.

24.

Cradock-O’Leary

Young

A. S.

Yano

E. M.

Wang

Lee

M. L.

(2002). Use of general medical services by VA patients with psychiatric disorders. Psychiatric Services, 53, 874-878.

25.

Cunningham

J. A.

McCambridge

(2011). Is alcohol dependence best viewed as a chronic relapsing disorder? Addiction, 107, 6-12. doi:10.1111/j.1360-0443.2011.03583.x

26.

Cunningham

(2009, August). Targeting chronically homeless veterans with HUD-VASH. Retrieved from http://www.urban.org/uploadedpdf/411991_chronically_homeless_veterans.pdf

27.

Davis

T. M.

Baer

J. S.

Saxon

A. J.

Kivlahan

D. R.

(2003). Brief motivational feedback improves post-incarceration treatment contact among veterans with substance use disorders. Drug and Alcohol Dependence, 69, 197-203.

28.

Department of Health and Human Services. (2013). Mechanisms of behavior change in the treatment of alcohol use disorders (R01). Retrieved from http://grants.nih.gov/grants/guide/pa-files/PAR-14-051.html

29.

Department of Veterans Affairs. (2010, October 18). National survey of Veterans, active duty service members, demobilized national guard and reserve members, family members, and surviving spouses: Final report. Retrieved from http://www.va.gov/vetdata/docs/SurveysAndStudies/NVSSurveyFinalWeightedReport.pdf

30.

Department of Veterans Affairs. (2012a). Homeless Veterans: About the initiative. Retrieved from http://www.va.gov/HOMELESS/about_the_initiative.asp

31.

Department of Veterans Affairs. (2012b). HOMES: Veterans Justice Outreach and Health Care for Re-Entry Veterans summary data. Unpublished manuscript.

32.

Department of Veterans Affairs. (2013). Make the connection: Shared experiences and support for Veterans. Retrieved from http://maketheconnection.net/

33.

Department of Veterans Affairs & Department of Defense. (2009). VA/DoD clinical practice guideline for management of substance use disorders (SUD). Washington, DC: Author. Retrieved from http://www.dcoe.mil/content/navigation/documents/sud_full_601f.pdf

34.

Dickstein

B. D.

Vogt

D. S.

Handa

Litz

B. T.

(2010). Targeting self-stigma in returning military personnel and veterans: A review of intervention strategies. Military Psychology, 22, 224-236.

35.

Drug Policy Alliance. (2009, November 4). Healing a broken system: Veterans battling addiction and incarceration (Issue Brief). Retrieved from http://www.drugpolicy.org/docUploads/DPA_IssueBrief_veterans.pdf

36.

Edens

E. L.

Kasprow

Tsai

Rosenheck

R. A.

(2011). Association of substance use and VA service-connected disability benefits with risk of homelessness among veterans. The American Journal on Addictions, 20, 412-419. doi:10.1111/j.1521-0391.2011.00166.x

37.

Edlund

M. J.

Booth

B. M.

Feldman

Z. L.

(2009). Perceived need for treatment for alcohol use disorders: Results from two national surveys. Psychiatric Services, 60, 1618-1628. doi:10.1176/appi.ps.60.12.1618

38.

Elbogen

E. B.

Wagner

H. R.

Johnson

S. C.

Kinneer

Kang

Vasterling

J. J.

. . .Beckham

J. C.

(2013). Are Iraq and Afghanistan veterans using mental health services? New data from a national random-sample survey. Psychiatric Services, 64, 134-141. doi:10.1176/appi.ps.004792011

39.

Erickson

S. K.

Rosenheck

R. A.

Trestman

R. L.

Ford

J. D.

Desai

R. A.

(2008). Risk of incarceration between cohorts of veterans with and without mental illness discharged from inpatient units. Psychiatric Services, 59, 178-183.

40.

Ettner

S. L.

Huang

Evans

Ash

D. R.

Hardy

Jourabchi

Hser

Y. I.

(2006). Benefit-cost in the California treatment outcome project: Does substance abuse treatment “pay for itself. Health Services Research, 41, 192-213. doi:10.1111/j.1475-6773.2005.00466.x

41.

Fairweather

Gambill

Tinney

(2010, August 17). Veterans in the justice system: Treatment of violent offenders. Los Angeles Daily Journal, p. 7. Retrieved from http://www.bwjp.org/files/bwjp/files/Veterans_in_the_Justice_System.pdf

42.

Foa

E. B.

Yusko

D. A.

McLean

C. P.

Suvak

M. K.

Bux

D. A.

Oslin

. . .Volipcelli

(2013). Concurrent naltrexone and prolonged exposure therapy for patients with comorbid alcohol dependence and PTSD: A randomized clinical trial. Journal of the American Medical Association, 310, 488-495. doi:10.1001/jama.2013.8268

43.

Friedmann

P. D.

Taxman

F. S.

Henderson

C. E.

(2007). Evidence-based treatment practices for drug-involved adults in the criminal justice system. Journal of Substance Abuse Treatment, 32, 267-277.

44.

Frisman

L. K.

Griffin-Fennell

(2009). Commentary: Suicide and incarcerated veterans—Don’t wait for the numbers. Journal of the American Academy of Psychiatry and the Law, 37, 92-94.

45.

Gibbs

D. A.

Olmsted

K. L. R.

Brown

J. M.

Clinton-Sherrod

A. M.

(2011). Dynamics of stigma for alcohol and mental health treatment among army soldiers. Military Psychology, 23, 36-51.

46.

Glaze

L. E.

(2011). Correctional population in the United States, 2010. Retrieved from http://www.bjs.gov/content/pub/pdf/cpus10.pdf

47.

Greenberg

G. A.

Rosenheck

R. A.

(2008). Jail incarceration, homelessness, and mental health: A national study. Psychiatric Services, 59, 170-177. doi:10.1176/appi.ps.59.2.170

48.

Greene-Shortridge

T. M.

Britt

T. W.

Castro

C. A.

(2007). The stigma of mental health problems in the military. Military Medicine, 172, 157-161.

49.

Harris

A. H.

Gifford

Hagedorn

Ekstrom

(2011). Substance use disorder QUERI strategic plan. Menlo Park, CA: VA Palo Alto Health Care System. Retrieved from http://www.queri.research.va.gov/about/strategic_plans/sud.pdf

50.

Hartwell

(2004). Triple stigma: Persons with mental illness and substance abuse problems in the criminal justice system. Criminal Justice Policy Review, 15, 84-99.

51.

Hawkins

E. J.

Grossbard

Benbow

Nacev

Kivlahan

D. R.

(2012). Evidence-based screening, diagnosis, and treatment of substance use disorders among veterans and military service personnel. Military Medicine, 177(8 Suppl.), 29-38.

52.

Heather

Smailes

Cassidy

(2008). Development of a readiness ruler for use with alcohol brief interventions. Drug and Alcohol Dependence, 98, 235-240.

53.

Held

Owens

G. P.

(2013). Stigmas and attitudes toward seeking mental health treatment in a sample of veterans and active duty service members. Traumatology, 19, 136-143.

54.

Hoge

C. W.

Castro

C. A.

Messer

S. C.

McGurk

Cotting

D. I.

Koffman

R. L.

(2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 13-22.

55.

Institute of Medicine. (2013). Substance use disorders in the U.S. Armed Forces. Retrieved from http://www.nap.edu/openbook.php?record_id=13441

56.

Karberg

J. C.

James

D. J.

(2005). Substance dependence, abuse, and treatment of jail inmates, 2002. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

57.

Kim

P. Y.

Britt

T. W.

Klocko

R. P.

Riviere

L. A.

Adler

A. B.

(2011). Stigma, negative attitudes about treatment, and utilization of mental health care among soldiers. Military Psychology, 23, 65-81.

58.

Kraybill

Zerger

(2003). Providing treatment for homeless people with substance use disorders: Case studies of six programs. Nashville, TN: National Health Care for the Homeless Council. Retrieved from http://www.nhchc.org/wp-content/uploads/2011/09/CA05RCaseStudies-FINAL5.pdf

59.

Krenek

Maisto

S. A.

Funderburk

J. S.

Drayer

(2011). Severity of alcohol problems and readiness to change alcohol use in primary care. Addictive Behaviors, 36, 512-515. doi:10.1016/j.addbeh.2010.12.023

60.

Lapham

G. T.

Hawkins

E. J.

Chavez

L. J.

Achtmeyer

C. E.

Williams

E. C.

Thomas

R. M.

. . .Bradley

K. A.

(2012). Feedback from recently returned veterans on an anonymous web-based brief alcohol intervention. Addiction Science & Clinical Practice, 7(1), Article 17. doi:10.1186/1940-0640-7-17

61.

Larimer

M. E.

Malone

D. K.

Garner

M. D.

Atkins

Burlingham

Lonczak

H. S.

. . .Marlatt

G. A.

(2009). Health care and public service utilization and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. Journal of the American Medical Association, 301, 1349-1357.

62.

LeBel

T. P.

(2012). Invisible stripes? Formerly incarcerated persons’ perceptions of stigma. Deviant Behavior, 33, 89-107.

63.

Legal Action Center. (2009). After prison: Roadblocks to reentry 2009 update. Retrieved from http://www.lac.org/roadblocks-toreentry/upload/lacreport/Roadblocks-to-Reentry–2009.pdf

64.

Leon

G. D.

Melnick

Kressel

Jainchill

(1994). Circumstances, motivation, readiness, and suitability (the CMRS scales): Predicting retention in therapeutic community treatment. The American Journal of Drug and Alcohol Abuse, 20, 495-515.

65.

Lillis

Hayes

S. C.

Bunting

Masuda

(2009). Teaching acceptance and mindfulness to improve the lives of the obese: A preliminary test of a theoretical model. Annals of Behavioral Medicine, 37, 58-69. doi:10.1007/s12160-009-9083-x

66.

Little

G. L.

(2006). MRT in drug courts: A comprehensive review of recidivism outcomes. Cognitive-Behavioral Treatment Review, 15, 1-6.

67.

Mallik-Kane

Visher

C. A.

(2008). Health and prisoner reentry: How physical, mental, and substance abuse conditions shape the process of reintegration. Retrieved from http://www.urban.org/UploadedPDF/411617_health_prisoner_reentry.pdf

68.

Marmar

C. R.

(2009). Mental health impact of Afghanistan and Iraq deployment: Meeting the challenge of a new generation of veterans. Depression and Anxiety, 26, 493-497.

69.

McFarling

D’Angelo

Drain

Gibbs

D. A.

Olmsted

K. L. R.

(2011). Stigma as a barrier to substance abuse and mental health treatment. Military Psychology, 23, 1-5.

70.

McGuire

(2007). Closing a front door to homelessness among veterans. The Journal of Primary Prevention, 28, 389-400. doi:10.1007/s10935-007-0091-y

71.

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

72.

McGuire

Rosenheck

R. A.

Kasprow

W. J.

(2003). Health status, service use, and costs among veterans receiving outreach services in jail or community settings. Psychiatric Services, 54, 201-207.

73.

McKay

J. R.

(2009). Treating substance use disorders with adaptive continuing care. Washington, DC: American Psychological Association.

74.

McLellan

A. T.

Lewis

D. C.

O’Brien

C. P.

Kleber

H. D.

(2000). Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. Journal of the American Medical Association, 284, 1689-1695. doi:10.1001/jama.284.13.1689

75.

McMurran

(2009). Motivational Interviewing with offenders: A systematic review. Legal and Criminological Psychology, 14, 83-100.

76.

McMurran

Ward

(2010). Treatment readiness, treatment engagement, and behaviour change. Criminal Behaviour and Mental Health, 20, 75-85.

77.

McNiel

D. E.

Binder

R. L.

Robinson

J. C.

(2005). Incarceration associated with homelessness, mental disorder, and co-occurring substance abuse. Psychiatric Services, 56, 840-846.

78.

Miller

W. R.

Rollnick

(2013). Motivational interviewing: Helping people change (3rd ed.). New York, NY: Guilford Press.

79.

Miller

W. R.

Tonigan

J. S.

(1996). Assessing drinkers’ motivation for change: The stages of change readiness and treatment eagerness scale (SOCRATES). In Marlatt

G. A.

VandenBos

G. R.

(Eds.), Addictive behaviors: Readings on etiology, prevention, and treatment (pp. 355-369). Washington, DC: American Psychological Association.

80.

Miller

W. R.

Zweben

DiClemente

C. C.

Rychtarik

R. G.

(1994). Motivational enhancement therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence (Project MATCH Monograph Series, Vol. 2, DHHS Publication No. 94-3723). Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.

81.

Milliken

C. S.

Auchterlonie

J. L.

Hoge

C. W.

(2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. Journal of the American Medical Association, 14, 2141-2148.

82.

Montgomery

A. E.

Hill

L. L.

Kane

Culhane

D. P.

(2013). Housing chronically homeless veterans: Evaluating the efficacy of a housing first approach to HUD-VASH. Journal of Community Psychology, 41, 505-514.

83.

Moore

E. C.

(2012). A mentor in combat Veterans court: Observations and challenges. Williamsburg, VA: National Center for State Courts. Retrieved from http://www.ncsc.org/%20sitecore/content/microsites/%20future-trends-2012/home/Courts-andtheCommunity/~/media/Microsites/Files/%20Future%20Trends%202012/PDFs/AMentor_Moore.ashx

84.

Mumola

C. J.

(2000). Veterans in prison or jail. Retrieved from http://bjs.gov/content/pub/pdf/vpj.pdf

85.

National Association of Drug Court Professionals. (2010). Veterans treatment courts: Giving our heroes at home the help they’ve earned. Retrieved from http://www.nadcp.org/sites/default/files/nadcp/VTC%20Brief.pdf

86.

National Association of State Alcohol and Drug Abuse Directors. (2009, September). Addressing the substance use disorder (SUD) service needs of returning veterans and their families: The training needs of state alcohol and other drug agencies and providers. Retrieved from http://partnersforrecovery.samhsa.gov/docs/Veterans_Report.pdf

87.

National Center for Posttraumatic Stress Disorder. (2013). PTSD Coach [Mobile application]. Retrieved from http://www.ptsd.va.gov/public/materials/apps/PTSDCoach.asp

88.

National Registry of Evidence-based Programs and Practices. (2007). Motivational enhancement therapy. Retrieved from http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=347

89.

Noonan

M. E.

Mumola

C. J.

(2007). Veterans in state and federal prison, 2004 (Bureau of Justice Statistics Special Report, No. NCJ 217199). Washington, DC: US Department of Justice.

90.

Oser

M. L.

McKellar

Moos

B. S.

Moos

R. H.

(2010). Changes in ambivalence mediate the relation between entering treatment and change in alcohol use and problems. Addictive Behaviors, 35, 367-369. doi:10.1016/j.addbeh.2009.10.024

91.

Osher

F.C.

(2005, November). Integrated mental health/substance abuse responses to justice involved persons with co-occurring disorders. Paper presented at the Evidence-Based Practice for Justice-Involved Individuals: Integrated Mental Health/Substance Abuse Expert Panel Meeting, Bethesda, MD. Retrieved from https://secure.addictioncounselorce.com/articles/101371/IntegratedMentalHealthPaper.pdf

92.

Osher

F. C.

(2008). Integrated mental health/substance abuse responses to justice involved persons with co-occurring disorders. Journal of Dual Diagnosis, 4, 3-33. doi:10.1300/J374v04n01_02

93.

Osher

F. C.

Steadman

H. J.

(2007). Adapting evidence-based practices for persons with mental illness involved with the criminal justice system. Psychiatric Services, 58, 1472-1478.

94.

Ouimette

Vogt

Wade

Tirone

Greenbaum

M. A.

Kimerling

. . . .Rosen

C. S.

(2011). Perceived barriers to care among Veterans Health Administration patients with posttraumatic stress disorder. Psychological Services, 8, 212-223.

95.

Pandiani

J. A.

Ochs

W. R.

Pomerantz

A. S.

(2010). Criminal justice involvement of armed forces veterans in two systems of care. Psychiatric Services, 61, 835-837. doi:10.1176/appi.ps.61.8.835

96.

Penn

D. L.

Couture

S. M.

(2002). Strategies for reducing stigma toward persons with mental illness. Word Psychiatry, 1(1), 20-21.

97.

Peters

R. H.

Bartoi

M. G.

Sherman

P. B.

(2008). Screening and assessment of co-occurring disorders in the justice system. Delmar, NY: CMHS National GAINS Center. Retrieved from http://gainscenter.samhsa.gov/pdfs/disorders/ScreeningAndAssessment.pdf

98.

Petzel

R. A.

(2012). VHA Handbook 1160.04: VHA programs for veterans with substance use disorders (SUD). Washington, DC: Department of Veterans Affairs. Retrieved from http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2498

99.

Pietrzak

Johnson

Goldstein

Malley

Southwick

(2009). Perceived stigma and barriers to mental health care utilization among OEF-OIF veterans. Psychiatric Services, 60, 1118-1122.

100.

Re-Entry Policy Council. (2005). Report of the Re-Entry Policy Council: Charting the safe and successful return of prisoners to the community. New York, NY: Council of State Governments.

101.

Resnick

Rosenheck

(2008). Integrating peer-provided services: A quasi-experimental study of recovery orientation, confidence, and empowerment. Psychiatric Services, 59, 1307-1314.

102.

Rieckhoff

Schleifer

McCarthy

(2012, March). IAVA 2012 Member Survey. New York, NY: Iraq and Afghanistan Veterans of America. Retrieved from http://media.iava.org/iava_2012_member_survey.pdf

103.

Rog

D. J.

(2004). The evidence on supported housing. Psychiatric Rehabilitation Journal, 27, 334-344. doi:10.2975/27.2004.334.344

104.

Roman

Travis

(2004). Taking stock: Housing, homelessness, and prisoner reentry. Washington, DC: Urban Institute.

105.

Rosenthal

McGuire

(2013). Incarcerated veterans. In Gideon

(Ed.), Special needs offenders in correctional institutions (pp. 345-376). Thousand Oaks, CA: Sage.

106.

Russell

R. T.

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

107.

Saxon

A. J.

Davis

T. M.

Sloan

K. L.

McKnight

K. M.

McFall

M. E.

Kivlahan

D. R.

(2001). Trauma, symptoms of posttraumatic stress disorder, and associated problems among incarcerated veterans. Psychiatric Services, 52, 959-964.

108.

Saxon

A. J.

Malte

C. A.

Sloan

K. L.

Baer

J. S.

Calsyn

D. A.

Nichol

. . .Kivlahan

D. R.

(2006). Randomized trial of onsite versus referral primary medical care for veterans in addictions treatment. Medical Care, 44, 334-342.

109.

Schaefer

J. A.

Ingudomnukul

Harris

A. H.

Cronkite

R. C.

(2005). Continuity of care practices and substance use disorder patients’ engagement in continuing care. Medical Care, 43, 1234-1241.

110.

Schwartz

Levitas

(2011). Restorative justice for veterans: The San Francisco sheriff’s department’s community of Veterans engaged in restoration (COVER). Washington University Journal of Law & Policy, 36, 47-63.

111.

Seal

K. H.

Abadjian

McCamish

Shi

Tarasovsky

Weingardt

(2012). A randomized controlled trial of telephone motivational interviewing to enhance mental health treatment engagement in Iraq and Afghanistan veterans. General Hospital Psychiatry, 34, 450-459.

112.

Smee

D. E.

McGuire

Garrick

Sreenivasan

Dow

Woehl

(2013). Critical concerns in Iraq/Afghanistan war veteran-forensic interface: Veterans treatment court as diversion in rural communities. The Journal of the American Academy of Psychiatry and the Law, 41, 256-262.

113.

Steadman

H. J.

Callahan

Clark Robbins

Vesselinov

McGuire

Morrissey

J. P.

(2014). Criminal justice and behavioral health care costs of mental health court participants: A six-year study. Psychiatric Services, 65, 1100-1104. doi:10.1176/appi.ps.201300375

114.

Stecker

Fortney

(2011). Barriers to mental health treatment engagement among veterans. In Ruzek

J. I.

Schnurr

P. P.

Vasterling

J. J.

Friedman

M. J.

(Eds.), Caring for veterans with deployment-related stress disorders (pp. 243-259). Washington, DC: American Psychological Association.

115.

Substance Abuse and Mental Health Services Administration. (1998). Implementing interventions for homeless individuals with co-occurring mental health and substance use disorders: A PATH technical assistance package. Retrieved from http://pathprogram.samhsa.gov/Resource/Implementing-Interventions-for-Homeless-Individuals-with-Co-Occurring-Mental-Health-and-Substance-Use-Disorders-A-PATH-Technical-Assistance-Package-22671.aspx

116.

Substance Abuse and Mental Health Services Administration. (2006). Developing a stigma reduction initiative (SAMHSA Pub No. SMA-4176). Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration.

117.

Substance Abuse and Mental Health Services Administration. (n.d.). Co-occurring disorders and military justice. Retrieved from http://media.samhsa.gov/co-occurring/topics/military-justice/index.aspx

118.

Swords to Plowshares. (2011). Veterans and criminal justice: A review of the literature. Retrieved from http://www.swords-to-plowshares.org/wp-content/uploads/Veterans-and-Criminal-Justic-Literature-Review.pdf

119.

Thornicroft

Brohan

Kassam

Lewis-Holmes

(2008). Reducing stigma and discrimination: Candidate interventions. International Journal of Mental Health Systems, 13, Article 3. doi:10.1186/1752-4458-2-3. Retrieved from http://www.ijmhs.com/content/pdf/1752-4458-2-3.pdf

120.

Tracy

Burton

Nich

Rounsaville

(2011). Utilizing peer mentorship to engage high recidivism substance-abusing patients in treatment. The American Journal of Drug and Alcohol Abuse, 37, 525-531. doi:10.3109/00952990.2011.600385

121.

Tsai

Kasprow

W. J.

Rosenheck

R. A.

(2013). Alcohol and drug use disorders among homeless veterans: Prevalence and association with supported housing outcomes. Addictive Behaviors, 39, 455-460. doi:10.1016/j.addbeh.2013.02.002

122.

Tsai

Rosenheck

R. A.

Kasprow

W. J.

McGuire

J. F.

(2013). Homelessness in a national sample of incarcerated veterans in state and federal prisons. Administration and Policy in Mental Health, 41(3), 360-367. doi:10.1007/s10488-013-0483-7

123.

Tsan

J. Y.

Zeber

J. E.

Stock

E. M.

Sun

Copeland

L. A.

(2012). Primary care–mental health integration and treatment retention among Iraq and Afghanistan war veterans. Psychological Services, 9, 336-348. doi:10.1037/a0028308

124.

Tsemberis

Gulcur

Nakae

(2004). Housing first, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. American Journal of Public Health, 94, 651-656.

125.

Vanderplasschen

Wolf

Rapp

R. C.

Broekart

(2007). Effectiveness of different models of case management for substance-abusing populations. Journal of Psychoactive Drugs, 39, 81-95.

126.

Veterans Affairs Office of Public and Intergovernmental Affairs. (2013, November 21). VA and HUD announce twenty-four percent reduction in Veterans’ homelessness since 2010. Retrieved from http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2499

127.

Veterans Benefits Administration. (2014). Veterans benefits administration. Retrieved from http://www.benefits.va.gov/benefits/

128.

Veterans Health Administration. (2011, October). VA services for Veterans involved in the justice system: VA’s Veterans Justice Outreach program. Washington, DC: Department of Veterans Affairs. Retrieved from http://gainscenter.samhsa.gov/cms-assets/documents/60082-789968.clarkhandout.pdf

129.

Veterans Health Administration. (2013, May 22). Using technology to improve access to mental health care. Washington, DC: Department of Veterans Affairs. Retrieved from http://www.va.gov/health/newsfeatures/20120813a.asp

130.

Vogt

(2011). Mental health-related beliefs as a barrier to service use for military personnel and veterans: A review. Psychiatric Services, 62, 135-142.

131.

Wain

R. M.

Wilbourne

P. L.

Harris

K. W.

Pierson

Teleki

Burling

T. A.

(2011). Motivational interview improves treatment entry in homeless veterans. Drug and Alcohol Dependence, 115, 113-119.

132.

Ward

Day

Howells

Birgden

(2004). The multifactor offender readiness model. Aggression and Violent Behavior, 9, 645-673. doi:10.1016/j.avb.2003.08.001

133.

Weaver

C. M.

Joseph

Dongon

S. N.

Fairweather

Ruzek

J. I.

(2013). Enhancing services response to crisis incidents involving veterans: A role for law enforcement and mental health collaboration. Psychological Services, 10, 66-72. doi:10.1037/a0029651

134.

Williams

E. C.

Kivlahan

D. R.

Saitz

Merrill

J. O.

Achtmeyer

C. E.

McCormick

K. A.

Bradley

K. A.

(2006). Readiness to change in primary care patients who screened positive for alcohol misuse. Annals of Family Medicine, 4, 213-220.

135.

Winn

J. L.

Shealy

S. E.

Kropp

G. J.

Felkins-Dohm

Gonzales-Nolas

Francis

(2013). Housing assistance and case management: Improving access to substance use disorder treatment for homeless veterans. Psychological Services, 10, 233-240. doi:10.1037/a0031051

136.

Winnick

T. A.

Bodkin

(2008). Anticipated stigma and stigma management among those to be labeled “ex-con.” Deviant Behavior, 29, 295-333.

137.

Wong

C. F.

Tsai

Klee

Udell

H. R.

Harkness

Middleton

(2013). Helping veterans with mental illness overcome civil legal issues: Collaboration between a Veterans Affairs psychosocial rehabilitation center and a nonprofit legal center. Psychological Services, 10, 73-78.

138.

Wortzel

H. S.

Blatchford

Conner

Adler

L. E.

Binswanger

I. A.

(2012). Risk of death for veterans on release from prison. The Journal of the American Academy of Psychiatry and the Law, 40, 348-354.