Legal and Clinical Research

Below are some suggested studies and references that may assist you in working with trauma-affected veterans.  Wherever “($)” appears, the resource is available commercially at the link provided.  To access the study, click on the title and it will take you to the PDF (when available) or the site where the study may be reviewed or purchased.

This compilation of research and references is a work in progress -- suggestions for additions to this page are always welcome and may be sent to postmaster@cvltf.org

 

The entire compilation of research may be found below, or follow these links to access specific sections:

Post-9/11 Veterans' Mental Health

Criminal Justice Issues

Evidence Based Treatment

Recommended Reading

 

 

 

POST-9/11 VETERANS' MENTAL HEALTH

Study reveals areas of the brain impacted by PTSD

EurekAlert!, The Global Source for Science News; Boston University Medical Center, 1/20/17

Mindfulness Practice in the Treatment of Traumatic Stress

U.S. Department of Veterans Affairs; PTSD: National Center for PTSD, last updated August 14, 2015

Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care. The New England Journal Of Medicine, 351(1), 13-22. doi:10.1056/NEJMoa040603

BACKGROUND The current combat operations in Iraq and Afghanistan have involved US military personnel in major ground combat and hazardous security duty. Studies are needed to systematically assess the mental health of members of the armed services who have participated in these operations and to inform policy with regard to the optimal delivery of mental health care to returning veterans. METHODS We studied members of 4 US combat infantry units (3 Army units and a Marine Corps unit) using an anonymous survey that was administered to the subjects either before their deployment to Iraq (n=2530) or 3 to 4 months after their return from combat duty in Iraq or Afghanistan (n=3671). The outcomes included major depression, generalized anxiety, and posttraumatic stress disorder (PTSD), which were evaluated on the basis of standardized, self-administered screening instruments. RESULTS Exposure to combat was significantly greater among those who were deployed to Iraq than among those deployed to Afghanistan. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (15.6% to 17.1%) than after duty in Afghanistan (11.2%) or before deployment to Iraq (9.3%); the largest difference was in the rate of PTSD. Of those whose responses were positive for a mental disorder, only 23% to 40% sought mental health care. Those whose responses were positive for a mental disorder were twice as likely as those whose responses were negative to report concern about possible stigmatization and other barriers to seeking mental health care. CONCLUSIONS This study provides an initial look at the mental health of members of the Army and the Marine Corps who were involved in combat operations in Iraq and Afghanistan. Our findings indicate that among the study groups there was a significant risk of mental health problems and that the subjects reported important barriers to receiving mental health services, particularly the perception of stigma among those most in need of such care. [ABSTRACT FROM AUTHOR]

 

The Untold Story of Military Sexual Assault

By Michael F. Matthews

November 24, 2013

 

Prospective Prediction of Functional Difficulties Among Recently Separated Veterans

Larson, G. E., & Norman, S. B. (2014). Prospective prediction of functional difficulties among recently separated Veterans. Journal Of Rehabilitation Research & Development, 51(3), 415-427. doi:10.1682/JRRD.2013.06.0135

Reports of functional problems are common among Veterans who served post-9/11 (more than 25% report functional difficulties in at least one domain). However, little prospective work has examined the risk and protective factors for functional difficulties among Veterans. In a sample of recently separated Marines, we used stepwise logistic and multiple regressions to identify predictors of functional impairment, including work-related problems, financial problems, unlawful behavior, activity limitations due to mental health symptoms, and perceived difficulty reintegrating into civilian life. Posttraumatic stress disorder symptoms assessed both before and after military separation significantly predicted functional difficulties across all domains except unlawful behavior. Certain outcomes, such as unlawful behavior and activity limitations due to mental health symptoms, were predicted by other or additional predictors. Although several forms of functioning were examined, the list was not exhaustive. The results highlight a number of areas where targeted interventions may facilitate the reintegration of military servicemembers into civilian life. [ABSTRACT FROM AUTHOR]

 

Criminal Justice Involvement, Trauma, and Negative Affect in Iraq and Afghanistan War Era Veterans

Elbogen, E. B., Johnson, S. C., Newton, V. M., Straits-Troster, K., Vasterling, J. J., Wagner, H., & Beckham, J. C. (2012). Criminal justice involvement, trauma, and negative affect in Iraq and Afghanistan war era veterans. Journal Of Consulting And Clinical Psychology, 80(6), 1097-1102. doi:10.1037/a0029967

Objective: Although criminal behavior in veterans has been cited as a growing problem, little is known about why some veterans are at increased risk for arrest. Theories of criminal behavior postulate that people who have been exposed to stressful environments or traumatic events and who report negative affect such as anger and irritability are at increased risk of antisocial conduct. Method: We hypothesized veterans with posttraumatic stress disorder (PTSD) or traumatic brain injury (TBI) who report anger/irritability would show higher rates of criminal arrests. To test this, we examined data in a national survey of N = 1,388 Iraq and Afghanistan war era veterans. Results: We found that 9% of respondents reported arrests since returning home from military service. Most arrests were associated with nonviolent criminal behavior resulting in incarceration for less than 2 weeks. Unadjusted bivariate analyses revealed that veterans with probable PTSD or TBI who reported anger/irritability were more likely to be arrested than were other veterans. In multivariate analyses, arrests were found to be significantly related to younger age, male gender, having witnessed family violence, prior history of arrest, alcohol/drug misuse, and PTSD with high anger/irritability but were not significantly related to combat exposure or TBI. Conclusions: Findings show that a subset of veterans with PTSD and negative affect may be at increased risk of criminal arrest. Because arrests were more strongly linked to substance abuse and criminal history, clinicians should also consider non-PTSD factors when evaluating and treating veterans with criminal justice involvement. (PsycINFO Database Record (c) 2013 APA, all rights reserved) (journal abstract)

 

Internal Anger and External Expressions of Aggression in OEF/OIF Veterans

Renshaw, K. D., & Kiddie, N. S. (2012). Internal anger and external expressions of aggression in OEF/OIF veterans. Military Psychology, 24(3), 221-235. doi:10.1080/08995605.2012.678197

National Guard/Reserve service members (n = 143) deployed to Operations Enduring/Iraqi Freedom completed measures of anger/aggression, coping, and PTSD. Regressions and path analyses revealed that PTSD and avoidant coping both contributed to elevated anger. Furthermore, PTSD exerted indirect effects on verbal and physical aggression via anger, with direct effects only on physical aggression. Younger age was unrelated to anger but directly related to greater verbal and physical aggression. These results contribute to a more comprehensive understanding of risk for aggression in veterans of recent conflicts; however, the generalizability is limited by sample characteristics (all National Guard/Reserve, mostly White, married, religious). (PsycINFO Database Record (c) 2014 APA, all rights reserved) (journal abstract)

 

Disparate Prevalence Estimates of PTSD Among Service Members Who Served in Iraq and Afghanistan: Possible Explanations

($)

Ramchand, R., Schell, T. L., Karney, B. R., Osilla, K., Burns, R. M., & Caldarone, L. (2010). Disparate prevalence estimates of PTSD among service members who served in Iraq and Afghanistan: Possible explanations. Journal Of Traumatic Stress, 23(1), 59-68. doi:10.1002/jts.20486

The authors reviewed 29 studies that provide prevalence estimates of posttraumatic stress disorder (PTSD) among service members previously deployed to Operations Enduring and Iraqi Freedom and their non-U.S. military counterparts. Studies vary widely, particularly in their representativeness and the way PTSD is defined. Among previously deployed personnel not seeking treatment, most prevalence estimates range from 5 to 20%. Prevalence estimates are generally higher among those seeking treatment: As many as 50% of veterans seeking treatment screen positive for PTSD, though much fewer receive a PTSD diagnosis. Combat exposure is the only correlate consistently associated with PTSD. When evaluating PTSD prevalence estimates among this population, researchers and policymakers should carefully consider the method used to define PTSD and the population the study sample represents.

 

Studies’ Estimates of PTSD Prevalence Rates for Returning Service Members Vary Widely

Rajeev Ramchand, Terry L. Schell, Benjamin R. Karney, Karen Chan Osilla, Rachel M. Burns, Leah B. Caldarone

RAND Corporation 2010

Summarizes analyses of existing posttraumatic stress disorder (PTSD) studies for war zone veterans, finding that the prevalence estimates vary widely and are linked to the use of different PTSD diagnostic definitions and divergent study samples.

 

Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq

Hoge, C. W., McGurk, D., Thomas, J. L., Cox, A. L., Engel, C. C., & Castro, C. A. (2008). Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq. New England Journal Of Medicine, 358(5), 453-463. doi:10.1056/NEJMoa072972

BACKGROUND: An important medical concern of the Iraq war is the potential long-term effect of mild traumatic brain injury, or concussion, particularly from blast explosions. However, the epidemiology of combat-related mild traumatic brain injury is poorly understood. METHODS: We surveyed 2525 U.S. Army infantry soldiers 3 to 4 months after their return from a year-long deployment to Iraq. Validated clinical instruments were used to compare soldiers reporting mild traumatic brain injury, defined as an injury with loss of consciousness or altered mental status (e.g., dazed or confused), with soldiers who reported other injuries. RESULTS: Of 2525 soldiers, 124 (4.9%) reported injuries with loss of consciousness, 260 (10.3%) reported injuries with altered mental status, and 435 (17.2%) reported other injuries during deployment. Of those reporting loss of consciousness, 43.9% met criteria for post-traumatic stress disorder (PTSD), as compared with 27.3% of those reporting altered mental status, 16.2% with other injuries, and 9.1% with no injury. Soldiers with mild traumatic brain injury, primarily those who had loss of consciousness, were significantly more likely to report poor general health, missed workdays, medical visits, and a high number of somatic and postconcussive symptoms than were soldiers with other injuries. However, after adjustment for PTSD and depression, mild traumatic brain injury was no longer significantly associated with these physical health outcomes or symptoms, except for headache. CONCLUSIONS: Mild traumatic brain injury (i.e., concussion) occurring among soldiers deployed in Iraq is strongly associated with PTSD and physical health problems 3 to 4 months after the soldiers return home. PTSD and depression are important mediators of the relationship between mild traumatic brain injury and physical health problems. N Engl J Med 2008;358:453-63. [ABSTRACT FROM AUTHOR]

 

Longitudinal Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning From the Iraq War

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. JAMA: Journal Of The American Medical Association, 298(18), 2141-2148. doi:10.1001/jama.298.18.2141

Context: To promote early identification of mental health problems among combat veterans, the Department of Defense initiated population-wide screening at 2 time points, immediately on return from deployment and 3 to 6 months later. A previous article focusing only on the initial screening is likely to have underestimated the mental health burden. Objective: To measure the mental health needs among soldiers returning from Iraq and the association of screening with mental health care utilization. Design, Setting, and Participants: Population-based, longitudinal descriptive study of the initial large cohort of 88235 US soldiers returning from Iraq who completed both a Post-Deployment Health Assessment (PDHA) and a Post-Deployment Health Re-Assessment (PDHRA) with a median of 6 months between the 2 assessments. Main Outcome Measures: Screening positive for posttraumatic stress disorder (PTSD), major depression, alcohol misuse, or other mental health problems; referral and use of mental health services. Results: Soldiers reported more mental health concerns and were referred at significantly higher rates from the PDHRA than from the PDHA. Based on the combined screening, clinicians identified 20.3% of active and 42.4% of reserve component soldiers as requiring mental health treatment. Concerns about interpersonal conflict increased 4-fold. Soldiers frequently reported alcohol concerns, yet very few were referred to alcohol treatment. Most soldiers who used mental health services had not been referred, even though the majority accessed care within 30 days following the screening. Although soldiers were much more likely to report PTSD symptoms on the PDHRA than on the PDHA, 49% to 59% of those who had PTSD symptoms identified on the PDHA improved by the time they took the PDHRA. There was no direct relationship of referral or treatment with symptom improvement. Conclusions: Rescreening soldiers several months after their return from Iraq identified a large cohort missed on initial screening. The large clinical burden recently reported among veterans presenting to Veterans Affairs facilities seems to exist within months of returning home, highlighting the need to enhance military mental health care during this period. Increased relationship problems underscore shortcomings in services for family members. Reserve component soldiers who had returned to civilian status were referred at higher rates on the PDHRA, which could reflect their concerns about their ongoing health coverage. Lack of confidentiality may deter soldiers with alcohol problems from accessing treatment. In the context of an overburdened system of care, the effectiveness of population mental health screening was difficult to ascertain. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

 

Mental Health Problems, Use of Mental Health Services, and Attrition From Military Service After Returning From Deployment to Iraq or Afghanistan

Hoge, C. W., Auchterlonie, J. L., & Milliken, C. S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA: Journal Of The American Medical Association, 295(9), 1023-1032. doi:10.1001/jama.295.9.1023

CONTEXT The US military has conducted population-level screening for mental health problems among all service members returning from deployment to Afghanistan, Iraq, and other locations. To date, no systematic analysis of this program has been conducted, and studies have not assessed the impact of these deployments on mental health care utilization after deployment. OBJECTIVES To determine the relationship between combat deployment and mental health care use during the first year after return and to assess the lessons learned from the postdeployment mental health screening effort, particularly the correlation between the screening results, actual use of mental health services, and attrition from military service. DESIGN, SETTING, AND PARTICIPANTS Population-based descriptive study of all Army soldiers and Marines who completed the routine postdeployment health assessment between May 1, 2003, and April 30, 2004, on return from deployment to Operation Enduring Freedom in Afghanistan (n = 16 318), Operation Iraqi Freedom (n = 222 620), and other locations (n = 64 967). Health care utilization and occupational outcomes were measured for 1 year after deployment or until leaving the service if this occurred sooner. MAIN OUTCOME MEASURES Screening positive for posttraumatic stress disorder, major depression, or other mental health problems; referral for a mental health reason; use of mental health care services after returning from deployment; and attrition from military service. RESULTS The prevalence of reporting a mental health problem was 19.1% among service members returning from Iraq compared with 11.3% after returning from Afghanistan and 8.5% after returning from other locations (P<.001). Mental health problems reported on the postdeployment assessment were significantly associated with combat experiences, mental health care referral and utilization, and attrition from military service. Thirty-five percent of Iraq war veterans accessed mental health services in the year after returning home; 12% per year were diagnosed with a mental health problem. More than 50% of those referred for a mental health reason were documented to receive follow-up care although less than 10% of all service members who received mental health treatment were referred through the screening program. CONCLUSIONS Combat duty in Iraq was associated with high utilization of mental health services and attrition from military service after deployment. The deployment mental health screening program provided another indicator of the mental health impact of deployment on a population level but had limited utility in predicting the level of mental health services that were needed after deployment. The high rate of using mental health services among Operation Iraqi Freedom veterans after deployment highlights challenges in ensuring that there are adequate resources to meet the mental health needs of returning veterans.

 

Impact of Combat Duty in Iraq and Afghanistan on the Mental Health of U.S. Soldiers: Findings from the Walter Reed Army Institute of Research Land Combat Study

Hoge, C.W.; Castro, C.A. (2005) Impact of Combat Duty in Iraq and Afghanistan on the Mental Health of U.S. Soldiers: Findings from the Walter Reed Army Institute of Research Land Combat Study. In Strategies to Maintain Combat Readiness during Extended  Deployments – A Human Systems Approach (pp. 11-1 – 11-6). Meeting Proceedings RTO-MP-HFM-124, Paper 11.  Neuilly-sur-Seine, France: RTO.

BACKGROUND.  A recent study has shown that over 12% of U.S. Soldiers and Marines who returned from combat duty in Iraq met criteria for post-traumatic stress disorder, a rate significantly higher than before deployment, and that Soldiers reported significant stigma and barriers to receiving needed mental health care (Hoge, Castro, et. al. N Engl J Med 2004).  The study has continued to examine the effects of combat duty on U.S. Soldiers in near real time as the war has progressed, and this paper will present the latest findings from this landmark study.  METHODS.  Over 25,000 surveys have been obtained from U.S. Soldiers and Marines before deployment, during deployment, and up to one year post-deployment.   Outcomes include major depression, generalized anxiety, post-traumatic stress disorder (PTSD), alcohol misuse, health risk behaviors, and family functioning.  RESULTS.  Soldiers deployed to Iraq have experienced sustained high levels of combat exposure.  The rate of screening positive for a mental disorder at 3 months post-deployment was significantly higher after duty in Iraq (15-17%) compared with Afghanistan (11%) or before deployment (9%), with the largest difference due to PTSD.  Less than 40% of screen positives sought mental health care, and there was a high rate of concern about stigma / other barriers to care.  CONCLUSIONS.  Combat duty in Iraq is associated with a significant risk of mental health problems and there is an important unmet need for mental health services and barriers to care.  New data will be presented on the prevalence rates and risk factors for mental health problems up to one-year post-deployment.

 

PTSD Symptoms, Demographic Characteristics, and Functional Status Among Veterans Treated in VA Primary Care Clinics

($)

Magruder, K. M., Frueh, B. C., Knapp, R. G., Johnson, M. R., Vaughan, J. A., Carson, T. C., Powell, D. A. and Hebert, R. (2004), PTSD symptoms, demographic characteristics, and functional status among veterans treated in VA primary care clinics. Journal of Traumatic Stress, 17: 293–301. doi: 10.1023/B:JOTS.0000038477.47249.c8

We hypothesized that PTSD symptomatology would have an inverse relationship with functional status and would vary as a function of sociodemographic variables. Primary care patients (N = 513) at two VA Medical Centers were randomly selected and recruited to participate. After adjustment for other demographic variables. PTSD symptom levels were significantly related to age (younger patients had more severe symptoms), employment status (disabled persons had higher symptom levels), war zone experience, and clinic location. PTSD symptomatology was inversely related to mental and physical functioning, even after control for potential confounding. These findings have implications for screening and service delivery in VA primary care clinics, and support the more general finding in the literature that PTSD is associated with impaired functioning.

 

Posttraumatic stress disorder: diagnosis and epidemiology, comorbidity and social consequences, biology and treatment.

($)

Brunello, N.; Davidson, J.; Deahl, M.; et al. 2001. Postraumatic Stress Disorder: Diagnostic and Epidemiology, Comorbidity and Social Consequences, Biology and Treatment. Neuropsychobiology 43:150–162.

Epidemiological studies clearly indicate that posttraumatic stress disorder (PTSD) is becoming a major health concern worldwide even if still poorly recognized and not well treated. PTSD commonly co-occurs with other psychiatric disorders, and several symptoms overlap with major depressive disorders, anxiety disorders and substance abuse; this may contribute to diagnostic confusion and underdiagnosis. This anxiety disorder provokes significant occupational, psychiatric, medical and psychosocial disability, and its consequences are enormously costly, not only to the survivors and their families, but also to the health care system and society. Work impairment associated with PTSD is very similar to the amount of work impairment associated with major depression. The pathophysiology of PTSD is multifactorial and involves dysregulation of the serotonergic as well as the noradrenergic system. A rational therapeutic approach should normalize the specific psychobiological alterations associated with PTSD. This can be achieved through the use of antidepressant drugs, mainly of those that potentiate serotonergic mechanisms. Recent double-blind placebo-controlled studies report the efficacy of selective serotonin reuptake inhibitors. Several cognitive-behavioral and psychosocial treatments have also been reported to be efficacious and could be considered when treating PTSD patients.

 

 

CRIMINAL JUSTICE ISSUES

CASE LAW

California Penal Code §1170.9

California Penal Code §1170.91

California Penal Code §1001.80

 

Court of Appeals of California, Second District, Division One

The People, Plaintiff and Respondent, v. James L. Williams, Defendant and Appellant

Filed June 23, 2011

 

Court of Appeals of California, Fourth District, Division Three

The People, Plaintiff and Respondent v. Elijah Leigh Ferguson, Defendant and Appellant.

Decided April 30, 2009

 

Supreme Court of the United States

George Porter, Jr. v. Bill McCollum, Attorney General of Florida, Et Al.

Decided November 30, 2009

 

In the United States District Court for the District Of Colorado

United States of America, v. Frederick W. Murphy

Lewis T. Babcock, Judge

Dated January 15, 2008

 

People v. Duncan (App. 3 Dist. 2003) 5 Cal.Rptr.3d 413, 112 Cal.App.4th 744.

Sentencing under statute purporting to provide alternative to probation or imprisonment for Vietnam combat veterans convicted of a felony was a nonexistent sentencing option for defendant who was convicted of gross vehicular manslaughter while intoxicated, even if defendant’s alleged alcoholism was a direct consequence of post-traumatic stress disorder (PTSD) incurred as a result of his service in Vietnam, where there was no federal law which authorized the receipt of defendant to a federal facility for treatment for substance abuse or psychological problems resulting from Vietnam combat service.

 

People v. Abdullah (App. 4 Dist. 1992) 9 Cal.Rptr2d 131, 6 Cal.App.4th 1728, review denied

Condition of sentencing pursuant to state statute allowing Vietnam veterans convicted of state felonies to be committed to federal corrections custody rather than state prison is that federal correctional authorities must be ready, willing, and able to receive defendant for service of his term of incarceration.

Absent federal law authorizing receipt into appropriate federal corrections programs of Vietnam veterans convicted of state felonies, state statute providing for sentence of Vietnam veterans to federal correctional custody in lieu of state prison was illusory and thus, trial court was not required to consider option of alternative federal rehabilitative commitment when sentencing Vietnam veteran.

Statute providing for a placement of Vietnam veterans convicted of state felonies in federal corrections custody rather than state prison required that federal program be part of federal prison system and did not include commitment to local, noncustodial programs.

 

People v. Bruhn (App. 1 Dist. 1989) 259 Cal.Rptr. 6, 210 Cal.App.3d 1195.

Trial court must affirmatively indicate exercise of discretion under this section whenever prima facie showing of eligibility has been made, and intelligent exercise of discretion cannot be inferred from silent record.

Trial court’s summary sentencing of defendant to state prison without considering alternative of commitment to federal facility for treatment for substance abuse or psychological problems resulting from Vietnam combat service required remand for proper exercise of discretion under this section; if on resentencing trial court found that defendant was suitable for alternative placement, court would be required to determine whether defendant was agreeable to such program and whether there was a federal facility authorized to accept him.

Defendant must made initial showing that he served in combat while member of Unites States armed forces and that he suffers from substance abuse or other psychological problems resulting from service to trigger provisions of this section, but, once defendant makes initial showing, trial court must then consider his suitability for federal incarceration for term imposed.

Defendant made sufficient preliminary showing that he was candidate for alternatice placement under this section, thus requiring trial court to consider federal treatment program alternative; record indicated that defendant served combat duty in Vietnam where he used heroin and other drugs, was having difficulty functioning in society following return to United States, at time of offense was homeless, and perpetrated offense to secure basic necessities of life.

 

People v. Ruby (App. 4 Dist. 1988) 251 Cal.Rptr. 339, 204 Cal.App.3d 462, review denied

Record did not show that trial court fully evaluated whether it was appropriate to commit defendant, who was drug-addicted, decorated Vietnam combat veteran, to custody of federal correctional authorities, rather than state prison, in prosecution for unlawfully possessing controlled substance; defendant’s substance abuse has been diagnosed as being causally related to combat experience.

 

People v. Lara (App. 3 Dist. 1984) 202 Cal.Rptr. 262, 155 Cal.App3d 570.

To render judgement providing for convicted Vietnam veteran’s incarceration in custody of federal correctional officials, court must hold evidentiary hearing and insure that appropriate federal program is available to receive defendant, and if so, court should commit defendant directly to custody of federal officials, but if not, court can only commit defendant to state prison with recommendation that director of corrections exercise his statutory discretion to transfer defendant to federal facility.

 

People v. Enriquez (App. 2 Dist. 1984) 205 Cal.Rptr. 238, 159 Cal.App.3d 1.

Defendant convicted of two counts of bank robbery, who showed that he had served two tours of duty in Vietnam, and who argued that robberies were prompted by his narcotics problem, fell far short of showing that he served in combat in Vietnam and that he suffered from a substance abuse as a result of his service, and thus, failed to show that he was entitled to be considered for commitment to custody of federal authorities for incarceration for term imposed.

 

People v. Galvan (App. 5 Dist. 1984) 202 Cal.Rptr. 594, 156 Cal.App.3d 144.

Where appropriate federal program for treatment of Vietnam combat veteran suffering from posttraumatic stress syndrome came into operation after defendant, a Vietnam veteran allegedly suffering from PTSD, was first sentenced, remand was required to give trial court opportunity to obtain recommendation of director of correction or board of prisons terms as to whether defendant’s sentencing and commitment previously ordered should be recalled and to place defendant in new federal program.

 

MILITARY JUSTICE

Reclaiming the Rehabilitative Ethic in Military Justice: The Suspended Punitive Discharge as a Method to Treat Military Offenders With PTSD and TBI and Reduce Recidivism

Major Evan R. Seamone

Summer 2011

Military attorney and author, Major Evan R. Seamone, proposes use of local veterans treatment courts to obtain treatment and preserve VA benefits for active duty wounded warriors facing court-martial charges in new article, “Reclaiming the Rehabilitative Ethic in Military Justice: The Suspended Punitive Discharge as a Method to Treat Military Offenders With PTSD and TBI and Reduce Recidivism,” published by The Military Law Review.

 

Post-Traumatic Stress Disorder & the Military Justice System

Cooke, Peyton. Post-Traumatic Stress Disorder & the Military Justice System (May 13, 2009). Mississippi Law Journal, Vol. 79, No. 3, 2010.

This article, in the main, addresses how the Military Justice system deals -- and ought to deal -- with military members who are suffering from post-traumatic stress disorder (PTSD), and commit crimes. It begins with a thorough overview of PTSD in the current military, and then moves on to analyze the topic through three particular lenses: punishing versus treating military members who suffer from PTSD in light of Retributivst theory; psychotherapist-patient privilege in the military as affected by the recent restructuring of military psychiatry; and how military courts’ own oft-ignored tradition of rights protection affects these issues. The paper concludes provisionally that, due to the nature of military society, the military must both punish and treat its members who commit crimes in order to have the best chance of reintegrating those members into the community; and that, while Department of Defense directives and other military law has arguably eliminated the psychotherapist-patient privilege in the military, military courts have an opportunity to restore and maintain the privilege in light of those courts’ tradition of protecting the interests and rights of military members.

 

POSTTRAUMATIC STRESS

The Correlation Between PTSD and Criminogenic Behaviors In Incarcerated Veterans

Fleming, M., Simpson, M., & Presecan, N. (2013). The Correlation Between PTSD and Criminogenic Behaviors In Incarcerated Veterans. Corrections Forum, 22(6), 37-40.

The article discusses the research study on the characteristics of post-traumatic stress disorder (PTSD) in incarcerated veterans. It highlights the problems associated with the link between PTSD and criminal behaviors, the prevalence of incarcerated veterans, and the link of PTSD with traumatic brain injury. It also explains the treatment options for PTSD.

 

Forensic Validity of a PTSD Diagnosis

Claudia Baker, MSW, MPH and Cessie Alfonso, LCSW

National Center for PTSD

Many types of civil and criminal court cases and litigation involve claims of Posttraumatic Stress Disorder. The diagnostic validity of these claims can impact directly upon the defense, plaintiff, or prosecutorial legal strategies, depending upon the nature of use in the case. It is important, therefore, for attorneys and others involved in the legal system to be able to assess the validity of PTSD evaluations and diagnoses. Although only an expert in PTSD can complete an in-depth review of the diagnostic methodology used in a case, it is helpful if those conducting initial reviews know some basic facts about PTSD and what constitutes a sound diagnosis.

 

Department of the Army: Policy Guidance on the Assessment and Treatment of Post-Traumatic Stress Disorder (PTSD)

 

PTSD as a Criminal Defense: A Review of Case Law

Berger, O., McNiel, D., & Binder, R. (2012). PTSD as a criminal defense: a review of case law. The Journal Of The American Academy Of Psychiatry And The Law, 40(4), 509-521.

Posttraumatic stress disorder (PTSD) has been offered as a basis for criminal defenses, including insanity, unconsciousness, self-defense, diminished capacity, and sentencing mitigation. Examination of case law (e.g., appellate decisions) involving PTSD reveals that when offered as a criminal defense, PTSD has received mixed treatment in the judicial system. Courts have often recognized testimony about PTSD as scientifically reliable. In addition, PTSD has been recognized by appellate courts in U.S. jurisdictions as a valid basis for insanity, unconsciousness, and self-defense. However, the courts have not always found the presentation of PTSD testimony to be relevant, admissible, or compelling in such cases, particularly when expert testimony failed to show how PTSD met the standard for the given defense. In cases that did not meet the standard for one of the complete defenses, PTSD has been presented as a partial defense or mitigating circumstance, again with mixed success.

 

PTSD and the Law: An update

PTSD Research Quarterly: Advancing Science and Promoting Understanding of Traumatic Stress

National Center for PTSD

Jim McGuire, PhD & Sean Clarke, JD

2011

 

Reinvigorating Actus Reus: The Case for Involuntary Actions by Veterans with Post-Traumatic Stress Disorder

Melissa Hamilton, Reinvigorating Actus Reus: The Case for Involuntary Actions by Veterans with Post-Traumatic Stress Disorder, 16 Berkeley J. Crim. L. 340 (2011).

In common law, criminal culpability rests on two basic foundations of criminal intent, or mens rea, and a voluntary act, which comprises the actus reus. While much of the litigation in criminal cases concerns assigning the appropriate mens rea concept to the particular defendant’s mental state, relatively little debate focuses on the element of actus reus. Indeed, case law and commentators generally have devoted scant attention to fleshing out the voluntary act concept despite the historical consensus of both utilitarians and retributivists that one should not be considered morally or legally culpable for his or her involuntary actions. This paper conceptualizes an overall need to reinvigorate the actus reus requirement as a fundamental principal of criminal culpability. It does so by employing a contemporary problem facing the criminal justice system of combat veterans with Post-Traumatic Stress Disorder (PTSD) who commit acts of unlawful violence, including homicide, either in reflexive actions or during dissociative states triggered by re-experiencing combat-related stresses. While the veterans are often convicted of criminal offenses, studies on PTSD substantively support an argument that such violence may actually be conceptualized as automatism and, therefore, should not qualify as voluntary acts justifying criminal culpability. For example, mental health professionals describe PTSD as a neuropsychiatric disorder that involves hypervigilance, and hyperreactivity. Modern combat training is a likely correlate with its emphasis on muscle memory and reflexive responsiveness in the use of lethal weapons, which are adaptive, survival behaviors in the field of battle. The relationship to automatism is also evident in that PTSD is not merely a cognitive disorder as studies have shown PTSD-related alterations to brain structure and function and neurophysiological performance. Thus, this contemporary problem of PTSD in veterans due to wartime service provides a fresh perspective on which to reconsider the importance of the voluntary act requirement of criminal law.

 

Post-Traumatic Stress Disorder in the Criminal Justice System: From Vietnam to Iraq and Afghanistan

Marcia G. Shein

September 2010

 

Exit Wounds: Current Issues Pertaining to Combat-Related PTSD of Relevance to the Legal System

($)

Tramontin, M. (2010). Exit Wounds: Current Issues Pertaining to Combat-Related PTSD of Relevance to the Legal System. Developments In Mental Health Law, 29(1), 23-47.

Written for those in the mental health and legal communities dealing with war veterans embroiled in the criminal justice system, this Article presents an overview of current issues pertaining to the diagnosis, assessment, and treatment of combat-related post-traumatic stress disorder (PTSD). The objective is to provide information that can assist the legal system when addressing PTSD-related issues of combat veterans charged with crimes, with a specific focus on those returning from Operations Enduring Freedom and Iraqi Freedom (OEF/OIF). As part of this discussion, insights from clinical practice for assessing and treating combat veterans are offered and considered in light of state of the art trends from the complex and evolving field of traumatic stress studies. [ABSTRACT FROM AUTHOR]

 

Studies’ Estimates of PTSD Prevalence Rates for Returning Service Members Vary Widely

Rajeev Ramchand, Terry L. Schell, Benjamin R. Karney, Karen Chan Osilla, Rachel M. Burns, Leah B. Caldarone

RAND Corporation 2010

Summarizes analyses of existing posttraumatic stress disorder (PTSD) studies for war zone veterans, finding that the prevalence estimates vary widely and are linked to the use of different PTSD diagnostic definitions and divergent study samples.

 

Disparate Prevalence Estimates of PTSD Among Service Members Who Served in Iraq and Afghanistan: Possible Explanations

($)

Ramchand, R., Schell, T. L., Karney, B. R., Osilla, K., Burns, R. M., & Caldarone, L. (2010). Disparate prevalence estimates of PTSD among service members who served in Iraq and Afghanistan: Possible explanations. Journal Of Traumatic Stress, 23(1), 59-68. doi:10.1002/jts.20486

The authors reviewed 29 studies that provide prevalence estimates of posttraumatic stress disorder (PTSD) among service members previously deployed to Operations Enduring and Iraqi Freedom and their non-U.S. military counterparts. Studies vary widely, particularly in their representativeness and the way PTSD is defined. Among previously deployed personnel not seeking treatment, most prevalence estimates range from 5 to 20%. Prevalence estimates are generally higher among those seeking treatment: As many as 50% of veterans seeking treatment screen positive for PTSD, though much fewer receive a PTSD diagnosis. Combat exposure is the only correlate consistently associated with PTSD. When evaluating PTSD prevalence estimates among this population, researchers and policymakers should carefully consider the method used to define PTSD and the population the study sample represents.

 

Posttraumatic Stress Disorder and Criminal Responsibility

Friel, A., White, T., & Hull, A. (2008). Posttraumatic stress disorder and criminal responsibility. Journal of Forensic Psychiatry & Psychology, 19(1), 64-85. doi:10.1080/14789940701594736

There has been an increased interest in the relationship between posttraumatic stress disorder (PTSD) and violence, and in the factors that mediate their linkage. PTSD is a common, often underdiagnosed, condition with high levels of psychiatric comorbidity. It often has poor outcomes, with many cases becoming chronic, leading to substantial costs both to the individual and society as a whole. In this paper we report on the literature on PTSD, its diagnosis, assessment, and treatment. The difficulties encountered when assessing PTSD – the subjective nature of the symptoms, the risk of malingering, and the possibility of secondary gain – have been highlighted. Assessment and treatment in forensic settings is further complicated by the possibility of perpetrator PTSD. We have reviewed the prevalence of PTSD with particular reference to offender and forensic populations. The association between PTSD and violence, its relevance across the spectrum of criminal responsibility, and relevant case law are explored.

 

Combat Veterans, Mental Health Issues, and the Death Penalty: Addressing the Impact of Post-Traumatic Stress Disorder and Traumatic Brain Injury

Anthony E. Giardino

May 2009

More than 1.5 million Americans have participated in combat operations in Iraq and Afghanistan over the past seven years. Some of these veterans have subsequently committed capital crimes and found themselves in our nation’s criminal justice system. This Essay argues that combat veterans suffering from post-traumatic stress disorder or traumatic brain injury at the time of their offenses should not be subject to the death penalty. Offering mitigating evidence regarding military training, post-traumatic stress disorder, and traumatic brain injury presents one means that combat veterans may use to argue for their lives during the sentencing phase of their trials. Alternatively, Atkins v. Virginia and Roper v. Simmons offer a framework for establishing a legislatively or judicially created categorical exclusion for these offenders, exempting them from the death penalty as a matter of law. By understanding how combat service and service-related injuries affect the personal culpability of these offenders, the legal system can avoid the consequences of sentencing to death America's mentally wounded warriors, ensuring that only the worst offenders are subject to the ultimate punishment.

 

Aggression Among Combat Veterans: Relationships With Combat Exposure and Symptoms of Posttraumatic Stress Disorder, Dysphoria, and Anxiety Severity of Posttraumatic Stress Disorder and Involvement with the Criminal Justice System

Taft, C., Vogt, D., Marshall, A., Panuzio, J., & Niles, B. (2007). Aggression among combat veterans: relationships with combat exposure and symptoms of posttraumatic stress disorder, dysphoria, and anxiety. Journal Of Traumatic Stress, 20(2), 135-145.

Prior research has revealed heightened aggressive behavior among veterans with PTSD. This study tested a model examining the interrelationships among combat exposure, posttraumatic stress disorder (PTSD) symptoms, dysphoric symptoms, and anxiety symptoms in predicting aggressive behavior in a sample of 265 male combat veterans seeking diagnostic assessment of PTSD. Combat exposure was indirectly associated with aggression primarily through its relationship with PTSD symptoms. Symptoms of PTSD were directly related to aggression, and indirectly related to aggression through dysphoric symptoms. Results highlight the role of PTSD symptoms and dysphoric symptoms with respect to aggressive behavior among this population, and suggest the relevance of aggression theory to the study of combat veterans.

 

Posttraumatic Intrusion, Avoidance, and Social Functioning: A 20-Year Longitudinal Study

($)

Solomon, Z., & Mikulincer, M. (2007). Posttraumatic intrusion, avoidance, and social functioning: A 20-year longitudinal study. Journal Of Consulting And Clinical Psychology, 75(2), 316-324. doi:10.1037/0022-006X.75.2.316

The study assesses posttraumatic intrusion, avoidance, and social functioning among 214 Israeli combat veterans from the first Lebanon War with and without combat stress reaction (CSR) 1, 2, 3, and 20 years after the war. CSR veterans reported higher intrusion and avoidance than did non-CSR veterans. With time, there was a decline in these symptoms. In addition, intrusion and avoidance were associated with problems in social functioning on a given year, and they longitudinally predicted social dysfunction 2, 3, and 20 years after the war. CSR veterans presented stronger temporal covariations between intrusion-avoidance and social functioning. The findings suggest that CSR is a marker for future psychopathology and point to the role of avoidance in social dysfunction. (PsycINFO Database Record (c) 2013 APA, all rights reserved) (journal abstract)

 

Post-traumatic Stress Disorder and the Casual Link to Crime: A Looming National Tragedy

Daniel, D. L. (2008). Post-traumatic Stress Disorder and the Casual Link to Crime: A Looming National Tragedy. US Army, US Army Combined Arms Center. doi:10.1037/e614642009-001

The purpose of this paper is to investigate if there is a correlation between PTSD and criminal behavior in soldiers that have been incarcerated after returning from the GWOT and to determine the obligations of the U.S. government/DoD to prevent, treat, and/or mitigate the problem. This study includes data collected, examined and analyzed from three primary sources. First, an existing study on PTSD and criminal behavior by James J. Collins and Susan L. Bailey which examines the correlation between PTSD and criminal behavior primarily in 1140 nonveteran North Carolina inmates. This study is included to establish whether a general causal link exists between PTSD and an incidence of violent criminal behavior. Next, statistical data compiled by the Bureau of Justice Statistics (BJS) section of the Office of Justice Programs, U.S. Department of Justice (DoJ) is analyzed for trends in incarceration rates among veterans in Federal and State correctional facilities. The BJS data is included to examine whether the incarceration rates of veterans for violent criminal offenses has peaked during and after periods of war. Finally, this study will look closely at aggregate exempt inmate data recently compiled by the administrative and mental health staff of the United States Disciplinary Barracks, Fort Leavenworth, Kansas (USDB). The data from the USDB is part of an ongoing survey of the inmates (n=440) to determine the incidence of PTSD and mental health disorders within the prisoner population for treatment purposes and program analysis. This paper explores the history of PTSD in previous conflicts, the characteristics of the disorder and briefly discusses current treatment approaches. The data presented, particularly the initial results of the current USDB survey, strongly supports the current hypothesis that there is a correlation between PTSD and criminal behavior in soldiers that have been incarcerated after returning from the GWOT. As such the final contribution of this paper is to offer some brief recommendations on what our national leaders should do to prevent or mitigate the impending problem in our society of more veterans involved in violent criminal behavior. (PsycEXTRA Database Record (c) 2013 APA, all rights reserved)

 

Attorneys as First-Responders: Recognizing the Destructive Nature of Posttraumatic Stress Disorder on the Combat Veteran’s Legal Decision-Making Process

Captain Evan R. Seamone

Winter 2009

 

The Veterans’ Lawyer as Counselor: Using Therapeutic Jurisprudence to Enhance Client Counseling For Combat Veterans with Posttraumatic Stress Disorder

Captain Evan R. Seamone

Winter 2009

 

PTSD Symptoms, Demographic Characteristics, and Functional Status Among Veterans Treated in VA Primary Care Clinics

($)

Magruder, K. M., Frueh, B. C., Knapp, R. G., Johnson, M. R., Vaughan, J. A., Carson, T. C., Powell, D. A. and Hebert, R. (2004), PTSD symptoms, demographic characteristics, and functional status among veterans treated in VA primary care clinics. Journal of Traumatic Stress, 17: 293–301. doi: 10.1023/B:JOTS.0000038477.47249.c8

We hypothesized that PTSD symptomatology would have an inverse relationship with functional status and would vary as a function of sociodemographic variables. Primary care patients (N = 513) at two VA Medical Centers were randomly selected and recruited to participate. After adjustment for other demographic variables. PTSD symptom levels were significantly related to age (younger patients had more severe symptoms), employment status (disabled persons had higher symptom levels), war zone experience, and clinic location. PTSD symptomatology was inversely related to mental and physical functioning, even after control for potential confounding. These findings have implications for screening and service delivery in VA primary care clinics, and support the more general finding in the literature that PTSD is associated with impaired functioning.

 

Does Early Psychological Intervention Promote Recovery From Posttraumatic Stress?

($)

Richard J. McNally, Richard A. Bryant, and Anke Ehlers

November 2003

In the wake of the terrorist attacks at the World Trade Center, more than 9,000 counselors went to New York City to offer aid to rescue workers, families, and direct victims of the violence of September 11, 2001. These mental health professionals assumed that many New Yorkers were at high risk for developing posttraumatic stress disorder (PTSD), and they hoped that their interventions would mitigate psychological distress and prevent the emergence of this syndrome. Typically developing in response to horrific, life-threatening events, such as combat, rape, and earthquakes, PTSD is characterized by reexperiencing symptoms (e.g., intrusive recollections of the trauma, nightmares), emotional numbing and avoidance of reminders of the trauma, and hyperarousal (e.g., exaggerated startle, difficulty sleeping). People vary widely in their vulnerability for developing PTSD in the wake of trauma. For example, higher cognitive ability and strong social support buffer people against PTSD, whereas a family or personal history of emotional disorder heightens risk, as does negative appraisal of one's stress reactions (e.g., as a sign of personal weakness) and dissociation during the trauma (e.g., feeling unreal or experiencing time slowing down). However, the vast majority of trauma survivors recover from initial posttrauma reactions without professional help. Accordingly, the efficacy of interventions designed to mitigate acute distress and prevent long-term psychopathology, such as PTSD, needs to be evaluated against the effects of natural recovery. The need for controlled evaluations of early interventions has only recently been widely acknowledged.

Psychological debriefing—the most widely used method—has undergone increasing empirical scrutiny, and the results have been disappointing. Although the majority of debriefed survivors describe the experience as helpful, there is no convincing evidence that debriefing reduces the incidence of PTSD, and some controlled studies suggest that it may impede natural recovery from trauma. Most studies show that individuals who receive debriefing fare no better than those who do not receive debriefing. Methodological limitations have complicated interpretation of the data, and an intense controversy has developed regarding how best to help people in the immediate wake of trauma.

Recent published recommendations suggest that individuals providing crisis intervention in the immediate aftermath of the event should carefully assess trauma survivors' needs and offer support as necessary, without forcing survivors to disclose their personal thoughts and feelings about the event. Providing information about the trauma and its consequences is also important. However, research evaluating the efficacy of such “psychological first aid” is needed.

Some researchers have developed early interventions to treat individuals who are already showing marked stress symptoms, and have tested methods of identifying those at risk for chronic PTSD. The single most important indicator of subsequent risk for chronic PTSD appears to be the severity or number of posttrauma symptoms from about 1 to 2 weeks after the event onward (provided that the event is over and that there is no ongoing threat).

Cognitive-behavioral treatments differ from crisis intervention (e.g., debriefing) in that they are delivered weeks or months after the trauma, and therefore constitute a form of psychotherapy, not immediate emotional first aid. Several controlled trials suggest that certain cognitive-behavioral therapy methods may reduce the incidence of PTSD among people exposed to traumatic events. These methods are more effective than either supportive counseling or no intervention.

In this monograph, we review risk factors for PTSD, research on psychological debriefing, recent recommendations for crisis intervention and the identification of individuals at risk of chronic PTSD, and research on early interventions based on cognitive-behavioral therapy. We close by placing the controversy regarding early aid for trauma survivors in its social, political, and economic context.

 

Posttraumatic stress disorder: diagnosis and epidemiology, comorbidity and social consequences, biology and treatment.

($)

Brunello, N.; Davidson, J.; Deahl, M.; et al. 2001. Postraumatic Stress Disorder: Diagnostic and Epidemiology, Comorbidity and Social Consequences, Biology and Treatment. Neuropsychobiology 43:150–162.

Epidemiological studies clearly indicate that posttraumatic stress disorder (PTSD) is becoming a major health concern worldwide even if still poorly recognized and not well treated. PTSD commonly co-occurs with other psychiatric disorders, and several symptoms overlap with major depressive disorders, anxiety disorders and substance abuse; this may contribute to diagnostic confusion and underdiagnosis. This anxiety disorder provokes significant occupational, psychiatric, medical and psychosocial disability, and its consequences are enormously costly, not only to the survivors and their families, but also to the health care system and society. Work impairment associated with PTSD is very similar to the amount of work impairment associated with major depression. The pathophysiology of PTSD is multifactorial and involves dysregulation of the serotonergic as well as the noradrenergic system. A rational therapeutic approach should normalize the specific psychobiological alterations associated with PTSD. This can be achieved through the use of antidepressant drugs, mainly of those that potentiate serotonergic mechanisms. Recent double-blind placebo-controlled studies report the efficacy of selective serotonin reuptake inhibitors. Several cognitive-behavioral and psychosocial treatments have also been reported to be efficacious and could be considered when treating PTSD patients.

 

 

Aggression and Its Correlates in Vietnam Veterans with and Without Chronic Post-Traumatic Stress Disorder

($)

Lasko, N.B., Guruits, T.V., Kuhne, A.A., Orr, S.P., & Pitman, R.K. (1994). Aggression and its correlates in Vietnam veterans with and without chronic post-traumatic stress disorder. Comprehensive Psychiatry, 35, 373-381.

This study measured self-reported aggression, hostility, and anger in Vietnam combat veterans with (n = 27) and without (n = 15) posttraumatic stress disorder (PTSD). On the Buss-Durkee Hostility Inventory, Past Feelings and Acts of Violence Scale, Episodic Dyscontrol Scale, and State-Trait Anger Expression Inventory (STAXI), PTSD subjects scored significantly higher than non-PTSD subjects, whose scores fell in the range reported for normative, noncombat populations. The PTSD versus non-PTSD group differences were not explained by combat exposure, which did not correlate significantly with the psychometric aggression measures. These findings suggest that increased aggression in war veterans is more appropriately regarded as a property of PTSD, rather than a direct consequence of military combat. The association between compromised neurologic and neuropsychologic status and the psychometric measures was modest and explained little of the group differences.

 

Paying the Price for Vietnam: Post-traumatic Stress Disorder and Criminal Behavior

Erlinder, C. P. (1984). Paying the price for Vietnam: Post-traumatic Stress Disorder and criminal behavior. Boston College Law Review, 25(2). 305-347.

 

The Vietnam Veteran on Trial: The Relation of Post-Traumatic Stress Disorder to Criminal Behavior

($)

Wilson, J. P., & Zigelbaum, S. D. (1983). The Vietnam Veteran on Trial: The Relation of Post-Traumatic Stress Disorder to Criminal Behavior. Behavioral Sciences & The Law, 1(3), 69-83.

The purpose of this paper is to conceptualize the relationship of Post-Traumatic Stress Disorder (PTSD) in Vietnam veterans to criminal behavior. A conceptual framework is discussed which proposes that the disposition to criminal behavior is determined by whether or not the veteran enters into the survivor mode of functioning as a behavioral defense mechanism against the disorder. It is hypothesized that there exists a relationship between the severity of PTSD and the tendency to commit illegal acts. The Vietnam Era Stress Inventory (Wilson and Krauss, 1980) was used to assess PTSD among a volunteer national sample of Vietnam combat veterans (N = 114) participating in the Veterans Administration's counseling program known as Operation Outreach. The results strongly supported the hypothesis and indicated that combat role variables, exposure to stressors in Vietnam and the severity of PTSD were significantly correlated with criminal acts. [ABSTRACT FROM AUTHOR]

 

TRAUMATIC BRAIN INJURY

Traumatic Brain Injury — Football, Warfare, and Long-Term Effect

DeKosky, S., Ikonomovic, M., & Gandy, S. (2010). Traumatic brain injury: football, warfare, and long-term effects. Minnesota Medicine, 93(12), 46-47.

Public awareness of the consequences of traumatic brain injury caused by participation in sports, vehicular crashes, and modern warfare has increased in recent years. This article describes what is currently understood about the pathogenesis of traumatic brain injury and goals for research that could lead to better understanding.

 

Combat Veterans, Mental Health Issues, and the Death Penalty: Addressing the Impact of Post-Traumatic Stress Disorder and Traumatic Brain Injury

Anthony E. Giardino

May 2009

More than 1.5 million Americans have participated in combat operations in Iraq and Afghanistan over the past seven years. Some of these veterans have subsequently committed capital crimes and found themselves in our nation’s criminal justice system. This Essay argues that combat veterans suffering from post-traumatic stress disorder or traumatic brain injury at the time of their offenses should not be subject to the death penalty. Offering mitigating evidence regarding military training, post-traumatic stress disorder, and traumatic brain injury presents one means that combat veterans may use to argue for their lives during the sentencing phase of their trials. Alternatively, Atkins v. Virginia and Roper v. Simmons offer a framework for establishing a legislatively or judicially created categorical exclusion for these offenders, exempting them from the death penalty as a matter of law. By understanding how combat service and service-related injuries affect the personal culpability of these offenders, the legal system can avoid the consequences of sentencing to death America's mentally wounded warriors, ensuring that only the worst offenders are subject to the ultimate punishment.

 

VETERANS AS DEFENDANTS

 Echoes of War: The Combat Veteran in Criminal Court

Brockton D.  Hunter

July 2014

Just as PTSD is a natural side effect of war, research also reveals veteran-committed crime waves in the wake of every major American conflict, particularly Vietnam. Even today, 40 years after that war, hundreds of thousands of psychologically injured Vietnam veterans are incarcerated, chronically addicted and/or homeless across our country. This session will explore the history of PTSD and its ties to criminal behavior. It will then explore the ways in which America and its criminal justice system can learn lessons from history and avoid mistakes made with past generations of troubled returning war veterans.

 

Prospective Prediction of Functional Difficulties Among Recently Separated Veterans

Larson, G. E., & Norman, S. B. (2014). Prospective prediction of functional difficulties among recently separated Veterans. Journal Of Rehabilitation Research & Development, 51(3), 415-427. doi:10.1682/JRRD.2013.06.0135

Reports of functional problems are common among Veterans who served post-9/11 (more than 25% report functional difficulties in at least one domain). However, little prospective work has examined the risk and protective factors for functional difficulties among Veterans. In a sample of recently separated Marines, we used stepwise logistic and multiple regressions to identify predictors of functional impairment, including work-related problems, financial problems, unlawful behavior, activity limitations due to mental health symptoms, and perceived difficulty reintegrating into civilian life. Posttraumatic stress disorder symptoms assessed both before and after military separation significantly predicted functional difficulties across all domains except unlawful behavior. Certain outcomes, such as unlawful behavior and activity limitations due to mental health symptoms, were predicted by other or additional predictors. Although several forms of functioning were examined, the list was not exhaustive. The results highlight a number of areas where targeted interventions may facilitate the reintegration of military servicemembers into civilian life. [ABSTRACT FROM AUTHOR]

 

The Correlation Between PTSD and Criminogenic Behaviors In Incarcerated Veterans

Fleming, M., Simpson, M., & Presecan, N. (2013). The Correlation Between PTSD and Criminogenic Behaviors In Incarcerated Veterans. Corrections Forum, 22(6), 37-40.

The article discusses the research study on the characteristics of post-traumatic stress disorder (PTSD) in incarcerated veterans. It highlights the problems associated with the link between PTSD and criminal behaviors, the prevalence of incarcerated veterans, and the link of PTSD with traumatic brain injury. It also explains the treatment options for PTSD.

 

Internal Anger and External Expressions of Aggression in OEF/OIF Veterans

Renshaw, K. D., & Kiddie, N. S. (2012). Internal anger and external expressions of aggression in OEF/OIF veterans. Military Psychology, 24(3), 221-235. doi:10.1080/08995605.2012.678197

National Guard/Reserve service members (n = 143) deployed to Operations Enduring/Iraqi Freedom completed measures of anger/aggression, coping, and PTSD. Regressions and path analyses revealed that PTSD and avoidant coping both contributed to elevated anger. Furthermore, PTSD exerted indirect effects on verbal and physical aggression via anger, with direct effects only on physical aggression. Younger age was unrelated to anger but directly related to greater verbal and physical aggression. These results contribute to a more comprehensive understanding of risk for aggression in veterans of recent conflicts; however, the generalizability is limited by sample characteristics (all National Guard/Reserve, mostly White, married, religious). (PsycINFO Database Record (c) 2014 APA, all rights reserved) (journal abstract)

 

Criminal Justice Involvement, Trauma, and Negative Affect in Iraq and Afghanistan War Era Veterans

Elbogen, E. B., Johnson, S. C., Newton, V. M., Straits-Troster, K., Vasterling, J. J., Wagner, H., & Beckham, J. C. (2012). Criminal justice involvement, trauma, and negative affect in Iraq and Afghanistan war era veterans. Journal Of Consulting And Clinical Psychology, 80(6), 1097-1102. doi:10.1037/a0029967

Objective: Although criminal behavior in veterans has been cited as a growing problem, little is known about why some veterans are at increased risk for arrest. Theories of criminal behavior postulate that people who have been exposed to stressful environments or traumatic events and who report negative affect such as anger and irritability are at increased risk of antisocial conduct. Method: We hypothesized veterans with posttraumatic stress disorder (PTSD) or traumatic brain injury (TBI) who report anger/irritability would show higher rates of criminal arrests. To test this, we examined data in a national survey of N = 1,388 Iraq and Afghanistan war era veterans. Results: We found that 9% of respondents reported arrests since returning home from military service. Most arrests were associated with nonviolent criminal behavior resulting in incarceration for less than 2 weeks. Unadjusted bivariate analyses revealed that veterans with probable PTSD or TBI who reported anger/irritability were more likely to be arrested than were other veterans. In multivariate analyses, arrests were found to be significantly related to younger age, male gender, having witnessed family violence, prior history of arrest, alcohol/drug misuse, and PTSD with high anger/irritability but were not significantly related to combat exposure or TBI. Conclusions: Findings show that a subset of veterans with PTSD and negative affect may be at increased risk of criminal arrest. Because arrests were more strongly linked to substance abuse and criminal history, clinicians should also consider non-PTSD factors when evaluating and treating veterans with criminal justice involvement. (PsycINFO Database Record (c) 2013 APA, all rights reserved) (journal abstract)

 

Military Suicides: Those We Might Yet Save

Penny Coleman

January 24, 2012

 

Prosecutor Pretrial Attitudes and Plea-Bargaining Behavior Toward Veterans With Posttraumatic Stress Disorder

($)

Wilson, J., Brodsky, S. L., Neal, T. S., & Cramer, R. J. (2011). Prosecutor pretrial attitudes and plea-bargaining behavior toward veterans with posttraumatic stress disorder. Psychological Services, 8(4), 319-331. doi:10.1037/a0025330

Prosecutors are handling increasing numbers of criminal cases concerning veterans from the wars in Iraq and Afghanistan who suffer from posttraumatic stress disorder (PTSD). How these prosecutors handle such cases may reflect their attitudes toward veterans or offenders with PTSD. In turn, their attitudes may affect perceptions of blameworthiness, as well as negotiations about sentencing during the pretrial stage. The present study investigated the effect of a defendant's military experience and mental health status (i.e., PTSD) on prosecutors' offers at the pretrial stage and their ratings of the defendant's blameworthiness. Prosecutors' offers were more lenient to stress-disordered veterans; specifically, they were offered more diversion programs as compared with veterans without PTSD and to other offenders with PTSD. Prosecutors also perceived veterans and those with PTSD as less criminally culpable; they also empathized and identified more with veterans and those with PTSD than nonveterans and offenders without PTSD. (PsycINFO Database Record (c) 2013 APA, all rights reserved) (journal abstract)

 

Keeping Veterans with PTSD out of the Justice System

Keeping Veterans with PTSD out of the Justice System. (2010). Keeping Veterans with PTSD out of the Justice System, 2. doi:10.1037/e553532011-001

This report discusses how in recent years, programs have been developed to keep war Veterans with mental health problems from being put in jail or prison. The programs aim to assist Veterans who become involved in the justice system to get treatment for mental health problems that may exist. This includes the numbers of Veterans returning from Afghanistan and Iraq. (PsycEXTRA Database Record (c) 2013 APA, all rights reserved)

 

Exit Wounds: Current Issues Pertaining to Combat-Related PTSD of Relevance to the Legal System

($)

Tramontin, M. (2010). Exit Wounds: Current Issues Pertaining to Combat-Related PTSD of Relevance to the Legal System. Developments In Mental Health Law, 29(1), 23-47.

Written for those in the mental health and legal communities dealing with war veterans embroiled in the criminal justice system, this Article presents an overview of current issues pertaining to the diagnosis, assessment, and treatment of combat-related post-traumatic stress disorder (PTSD). The objective is to provide information that can assist the legal system when addressing PTSD-related issues of combat veterans charged with crimes, with a specific focus on those returning from Operations Enduring Freedom and Iraqi Freedom (OEF/OIF). As part of this discussion, insights from clinical practice for assessing and treating combat veterans are offered and considered in light of state of the art trends from the complex and evolving field of traumatic stress studies. [ABSTRACT FROM AUTHOR]

 

Last Stand? The Criminal Responsibility of War Veterans Returning from Iraq and Afghanistan with Posttraumatic Stress Disorder

Hafemeister, Thomas L. and Stockey, Nicole A., Last Stand? The Criminal Responsibility of War Veterans Returning from Iraq and Afghanistan with Post-Traumatic Stress Disorder (March 4, 2010). Indiana Law Journal, Vol. 85, No. 1, p. 87, 2010; Virginia Public Law and Legal Theory Research Paper No. 2009-06.

As more psychologically-scarred troops return from combat in Iraq and Afghanistan, society's focus on and concern for these troops and their psychological disorders has increased. With this increase and with associated studies confirming the validity of the Post-Traumatic Stress Disorder (PTSD) diagnosis and the genuine impact of PTSD on the behavior of war veterans, greater weight may be given to the premise that PTSD is a mental disorder that provides grounds for a "mental status defense", such as insanity, a lack of mens rea, or self-defense. Although considerable impediments remain, given the current political climate, Iraq and Afghanistan War veterans are in a better position to succeed in these defenses than Vietnam War veterans were a generation ago. This Article explores the prevalence and impact of PTSD, particularly in war veterans, the relevance of this disorder to the criminal justice system, and the likely evolution of related mental status defenses as Iraq and Afghanistan War veterans return from combat.

 

Veterans’ Courts and Criminal Responsibility: A Problem Solving History & Approach to the Liminality of Combat Trauma

Holbrook, Justin G. (2010). Veterans’ Courts and Criminal Responsibility: A Problem Solving History & Approach to the Liminality of Combat Trauma. Social Science Research Network. Retrieved from http://ssrn.com/abstract=1706829

In September 2010, a federal judge dismissed a criminal case involving a veteran accused of assaulting a federal police officer to allow the case to be heard by the Buffalo Veterans Treatment Court, a division of Buffalo City Court. For those involved in veterans’ advocacy and treatment, the case is significant for a number of reasons. First, it is the first criminal case nationwide to be transferred from federal court to a local veterans treatment court where the goal is to treat - rather than simply punish - those facing the liminal effects of military combat. Second, the case reignites the still unsettled controversy over whether problem-solving courts generally, and veterans courts specifically, unfairly shift the focus of justice away from the retributive interests of victims to the rehabilitative interests of perpetrators. Third, the case serves as a signal reminder to all justice system stakeholders, including parties, judges, attorneys, and treatment professionals, of the potential benefits of sidestepping courtroom adversity in favor of a coordinated effort that seeks to ameliorate victim concerns while advancing treatment opportunities for veterans suffering from combat-related trauma. This chapter explores these issues in light of the history of combat-related trauma and the development of veterans’ treatment courts around the country.

 

Correlates of Anger and Hostility in Iraq and Afghanistan War Veterans

Elbogen, E., Wagner, H., Fuller, S., Calhoun, P., Kinneer, P., & Beckham, J. (2010). Correlates of anger and hostility in Iraq and Afghanistan war veterans. The American Journal Of Psychiatry, 167(9), 1051-1058. doi:10.1176/appi.ajp.2010.09050739

Objective: As troops return from Iraq and Afghanistan to civilian life, clinicians are starting to grapple with how best to detect those at risk of postdeployment adjustment problems. Data reveal the presence of mental health problems in these soldiers, including posttraumatic stress disorder (PTSD), head injury, and alcohol abuse. Each of these conditions has been associated with elevated anger and hostility in veterans from previous conflicts. The authors sought to identify variables empirically related to anger and hostility in Iraq and Afghanistan veterans. Method: A total of 676 veterans who served since September 11, 2001, and who volunteered to participate in research studies were interviewed with instruments designed to collect information on psychiatric symptoms, health, and possible postdeployment adjustment issues. The primary outcome measures were variables measuring aggressive impulses or urges, difficulty managing anger, and perceived problems controlling violent behavior. Results: The three outcome measures were each significantly associated with PTSD hyperarousal symptoms. Other PTSD symptoms were less strongly and less consistently linked to anger and hostility. Traumatic brain injury and alcohol misuse were related to the outcome variables in bivariate but not multivariate analyses. Distinct sets of demographic, historical, and military-related variables were associated with the different facets of anger and hostility measured. Conclusions: The results underscore the need to tailor interventions individually to address anger and hostility effectively and to develop theoretically sophisticated, evidence-based knowledge to identify service members at risk of problematic postdeployment adjustment.

 

Antidepressant Drug Effects and Depression Severity: A Patient-Level Meta-analysis

Fournier, J. C., DeRubeis, R. J., Hollon, S. D., Dimidjian, S., Amsterdam, J. D., Shelton, R. C., & Fawcett, J. (2010). Antidepressant drug effects and depression severity: A patient-level meta-analysis. JAMA: Journal Of The American Medical Association, 303(1), 47-53. doi:10.1001/jama.2009.1943

Context: Antidepressant medications represent the best established treatment for major depressive disorder, but there is little evidence that they have a specific pharmacological effect relative to pill placebo for patients with less severe depression. Objective: To estimate the relative benefit of medication vs placebo across a wide range of initial symptom severity in patients diagnosed with depression. Data Sources: PubMed, PsycINFO, and the Cochrane Library databases were searched from January 1980 through March 2009, along with references from meta-analyses and reviews. Study Selection: Randomized placebo-controlled trials of antidepressants approved by the Food and Drug Administration in the treatment of major or minor depressive disorder were selected. Studies were included if their authors provided the requisite original data, they comprised adult outpatients, they included a medication vs placebo comparison for at least 6 weeks, they did not exclude patients on the basis of a placebo washout period, and they used the Hamilton Depression Rating Scale (HDRS). Data from 6 studies (718 patients) were included. Data Extraction: Individual patient-level data were obtained from study authors. Results: Medication vs placebo differences varied substantially as a function of baseline severity. Among patients with HDRS scores below 23, Cohen d effect sizes for the difference between medication and placebo were estimated to be less than 0.20 (a standard definition of a small effect). Estimates of the magnitude of the superiority of medication over placebo increased with increases in baseline depression severity and crossed the threshold defined by the National Institute for Clinical Excellence for a clinically significant difference at a baseline HDRS score of 25. Conclusions: The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

 

Post-Traumatic Stress Disorder in the Criminal Justice System: From Vietnam to Iraq and Afghanistan

Marcia G. Shein

September 2010

 

Mental Health and Other Risk Factors for Jail Incarceration among Male Veterans

($)

Greenberg, G., & Rosenheck, R. (2009). Mental health and other risk factors for jail incarceration among male veterans. The Psychiatric Quarterly, 80(1), 41-53. doi:10.1007/s11126-009-9092-8

Data derived from the 2002 Survey of Inmates in Local Jails and the 2000 National Survey of Veterans show that having mental health problems in addition to such sociodemographic characteristics as being a member of a minority group, not being married, having less education, and being younger are risk factors for incarceration among veterans, as they are for the general population. As in previous studies veterans who served during the Vietnam Era and to an even greater extent, those who served in the early years of the All Volunteer Force were at greater risk of incarceration than veterans from the most recent period of the AVF, after controlling for age and other factors.

 

Combat Veterans, Mental Health Issues, and the Death Penalty: Addressing the Impact of Post-Traumatic Stress Disorder and Traumatic Brain Injury

Anthony E. Giardino

May 2009

More than 1.5 million Americans have participated in combat operations in Iraq and Afghanistan over the past seven years. Some of these veterans have subsequently committed capital crimes and found themselves in our nation’s criminal justice system. This Essay argues that combat veterans suffering from post-traumatic stress disorder or traumatic brain injury at the time of their offenses should not be subject to the death penalty. Offering mitigating evidence regarding military training, post-traumatic stress disorder, and traumatic brain injury presents one means that combat veterans may use to argue for their lives during the sentencing phase of their trials. Alternatively, Atkins v. Virginia and Roper v. Simmons offer a framework for establishing a legislatively or judicially created categorical exclusion for these offenders, exempting them from the death penalty as a matter of law. By understanding how combat service and service-related injuries affect the personal culpability of these offenders, the legal system can avoid the consequences of sentencing to death America's mentally wounded warriors, ensuring that only the worst offenders are subject to the ultimate punishment.

 

Posttraumatic Stress Disorder and Criminal Responsibility

Friel, A., White, T., & Hull, A. (2008). Posttraumatic stress disorder and criminal responsibility. Journal of Forensic Psychiatry & Psychology, 19(1), 64-85. doi:10.1080/14789940701594736

There has been an increased interest in the relationship between posttraumatic stress disorder (PTSD) and violence, and in the factors that mediate their linkage. PTSD is a common, often underdiagnosed, condition with high levels of psychiatric comorbidity. It often has poor outcomes, with many cases becoming chronic, leading to substantial costs both to the individual and society as a whole. In this paper we report on the literature on PTSD, its diagnosis, assessment, and treatment. The difficulties encountered when assessing PTSD – the subjective nature of the symptoms, the risk of malingering, and the possibility of secondary gain – have been highlighted. Assessment and treatment in forensic settings is further complicated by the possibility of perpetrator PTSD. We have reviewed the prevalence of PTSD with particular reference to offender and forensic populations. The association between PTSD and violence, its relevance across the spectrum of criminal responsibility, and relevant case law are explored.

 

Early Intervention for Trauma: Where Are We and Where Do We Need to Go? A Commentary

($)

Litz, B. T. (2008), Early intervention for trauma: Where are we and where do we need to go? A commentary. Journal of Traumatic Stress, 21: 503–506. doi: 10.1002/jts.20373

In this commentary, the author underscores the importance of early intervention for trauma and describes the challenges that lie ahead for researchers, decision makers, and care providers. The author also provides a review of where things stand, briefly reviews psychological first aid strategies, and underscores where we need to go from here. Although the field has advanced considerably in the last decade or so, and there are compelling trials underway, there is much work that needs to be done, especially in terms of effectiveness and the task of integrating early intervention into various work cultures, such as the military.

 

Profile of 100 Incarcerated Veterans: Alameda County, California - 2012

 

Veterans in State and Federal Prison, 2004

Noonan, M. E., & Mumola, C. J. (2007). Veterans in State and Federal Prison, 2004. Veterans In State And Federal Prison, 2004, 1-16. doi:10.1037/e640312007-001

Reports on veterans who are inmates in state and federal prisons. Demographic characteristics, offense types, co-occurring substance use and mental health problems are addressed. Data in this report were based on personal interviews with prisoners, conducted through the Survey of Inmates in State and Federal Correctional Facilities, 2004. Conducted every 5 or 6 years since 1974 (Federal facilities were added for the first time in 1991), the inmate surveys are the only national source of detailed information on criminal offenders, including special populations such as military veterans. (PsycEXTRA Database Record (c) 2013 APA, all rights reserved)

 

Veterans in Prison or Jail

Bureau of Justice Statistics Special Report

January 2000

 

Medication Madness: How Psychiatric Drugs Cause Violence, Suicide, and Crime

Dr. Peter Breggin

September 13, 2009

 

Post-traumatic Stress Disorder and the Casual Link to Crime: A Looming National Tragedy

Daniel, D. L. (2008). Post-traumatic Stress Disorder and the Casual Link to Crime: A Looming National Tragedy. US Army, US Army Combined Arms Center. doi:10.1037/e614642009-001

The purpose of this paper is to investigate if there is a correlation between PTSD and criminal behavior in soldiers that have been incarcerated after returning from the GWOT and to determine the obligations of the U.S. government/DoD to prevent, treat, and/or mitigate the problem. This study includes data collected, examined and analyzed from three primary sources. First, an existing study on PTSD and criminal behavior by James J. Collins and Susan L. Bailey which examines the correlation between PTSD and criminal behavior primarily in 1140 nonveteran North Carolina inmates. This study is included to establish whether a general causal link exists between PTSD and an incidence of violent criminal behavior. Next, statistical data compiled by the Bureau of Justice Statistics (BJS) section of the Office of Justice Programs, U.S. Department of Justice (DoJ) is analyzed for trends in incarceration rates among veterans in Federal and State correctional facilities. The BJS data is included to examine whether the incarceration rates of veterans for violent criminal offenses has peaked during and after periods of war. Finally, this study will look closely at aggregate exempt inmate data recently compiled by the administrative and mental health staff of the United States Disciplinary Barracks, Fort Leavenworth, Kansas (USDB). The data from the USDB is part of an ongoing survey of the inmates (n=440) to determine the incidence of PTSD and mental health disorders within the prisoner population for treatment purposes and program analysis. This paper explores the history of PTSD in previous conflicts, the characteristics of the disorder and briefly discusses current treatment approaches. The data presented, particularly the initial results of the current USDB survey, strongly supports the current hypothesis that there is a correlation between PTSD and criminal behavior in soldiers that have been incarcerated after returning from the GWOT. As such the final contribution of this paper is to offer some brief recommendations on what our national leaders should do to prevent or mitigate the impending problem in our society of more veterans involved in violent criminal behavior. (PsycEXTRA Database Record (c) 2013 APA, all rights reserved)

 

Attorneys as First-Responders: Recognizing the Destructive Nature of Posttraumatic Stress Disorder on the Combat Veteran’s Legal Decision-Making Process

Captain Evan R. Seamone

Winter 2009

 

The Veterans’ Lawyer as Counselor: Using Therapeutic Jurisprudence to Enhance Client Counseling For Combat Veterans with Posttraumatic Stress Disorder

Captain Evan R. Seamone

Winter 2009

 

Aggression Among Combat Veterans: Relationships With Combat Exposure and Symptoms of Posttraumatic Stress Disorder, Dysphoria, and Anxiety Severity of Posttraumatic Stress Disorder and Involvement with the Criminal Justice System

Taft, C., Vogt, D., Marshall, A., Panuzio, J., & Niles, B. (2007). Aggression among combat veterans: relationships with combat exposure and symptoms of posttraumatic stress disorder, dysphoria, and anxiety. Journal Of Traumatic Stress, 20(2), 135-145.

Prior research has revealed heightened aggressive behavior among veterans with PTSD. This study tested a model examining the interrelationships among combat exposure, posttraumatic stress disorder (PTSD) symptoms, dysphoric symptoms, and anxiety symptoms in predicting aggressive behavior in a sample of 265 male combat veterans seeking diagnostic assessment of PTSD. Combat exposure was indirectly associated with aggression primarily through its relationship with PTSD symptoms. Symptoms of PTSD were directly related to aggression, and indirectly related to aggression through dysphoric symptoms. Results highlight the role of PTSD symptoms and dysphoric symptoms with respect to aggressive behavior among this population, and suggest the relevance of aggression theory to the study of combat veterans.

 

Severity of Posttraumatic Stress Disorder and Involvement with the Criminal Justice System

($)

Calhoun, P. S., Malesky Jr., L., Bosworth, H. B., & Beckham, J. C. (2004). Severity of Posttraumatic Stress Disorder and Involvement with the Criminal Justice System. Journal Of Trauma Practice, 3(3), 1-16. doi:10.1300/J189v03n03_01

Two hundred and forty-one Vietnam combat veterans with chronic posttraumatic stress disorder (PTSD) completed measures of PTSD symptom severity, combat exposure, depression, hostility, interpersonal violence, substance abuse, and arrest history. The majority of veterans with PTSD (63%) reported being arrested at least once after returning from Vietnam. Logistic regression analyses indicated that PTSD severity was positively correlated with arrest history even when other variables associated with criminal behavior were taken into account. Recommendations for evaluation and treatment of individuals with PTSD who are at risk of becoming involved with the criminal justice system are discussed. [ABSTRACT FROM AUTHOR]

 

Aggression and Its Correlates in Vietnam Veterans with and Without Chronic Post-Traumatic Stress Disorder

($)

Lasko, N.B., Guruits, T.V., Kuhne, A.A., Orr, S.P., & Pitman, R.K. (1994). Aggression and its correlates in Vietnam veterans with and without chronic post-traumatic stress disorder. Comprehensive Psychiatry, 35, 373-381.

This study measured self-reported aggression, hostility, and anger in Vietnam combat veterans with (n = 27) and without (n = 15) posttraumatic stress disorder (PTSD). On the Buss-Durkee Hostility Inventory, Past Feelings and Acts of Violence Scale, Episodic Dyscontrol Scale, and State-Trait Anger Expression Inventory (STAXI), PTSD subjects scored significantly higher than non-PTSD subjects, whose scores fell in the range reported for normative, noncombat populations. The PTSD versus non-PTSD group differences were not explained by combat exposure, which did not correlate significantly with the psychometric aggression measures. These findings suggest that increased aggression in war veterans is more appropriately regarded as a property of PTSD, rather than a direct consequence of military combat. The association between compromised neurologic and neuropsychologic status and the psychometric measures was modest and explained little of the group differences.

 

The “Vietnam Syndrome’’ Defense: A “G.I. Bill of Criminal Rights”?

Samuel Pyeatt Menefee

February 1985

 

Paying the Price for Vietnam: Post-traumatic Stress Disorder and Criminal Behavior

Erlinder, C. P. (1984). Paying the price for Vietnam: Post-traumatic Stress Disorder and criminal behavior. Boston College Law Review, 25(2). 305-347.

 

The Vietnam Veteran on Trial: The Relation of Post-Traumatic Stress Disorder to Criminal Behavior

($)

Wilson, J. P., & Zigelbaum, S. D. (1983). The Vietnam Veteran on Trial: The Relation of Post-Traumatic Stress Disorder to Criminal Behavior. Behavioral Sciences & The Law, 1(3), 69-83.

The purpose of this paper is to conceptualize the relationship of Post-Traumatic Stress Disorder (PTSD) in Vietnam veterans to criminal behavior. A conceptual framework is discussed which proposes that the disposition to criminal behavior is determined by whether or not the veteran enters into the survivor mode of functioning as a behavioral defense mechanism against the disorder. It is hypothesized that there exists a relationship between the severity of PTSD and the tendency to commit illegal acts. The Vietnam Era Stress Inventory (Wilson and Krauss, 1980) was used to assess PTSD among a volunteer national sample of Vietnam combat veterans (N = 114) participating in the Veterans Administration's counseling program known as Operation Outreach. The results strongly supported the hypothesis and indicated that combat role variables, exposure to stressors in Vietnam and the severity of PTSD were significantly correlated with criminal acts. [ABSTRACT FROM AUTHOR]

 

FAMILY ISSUES AND DOMESTIC VIOLENCE

Returning from the War Zone A Guide for Families of Military Members

September 2010

 

Domestic Violence, PTSD and Brain Injury:  Military and Civilian Challenges

Part 1

Part 2

Deborah D. Tucker for the National Center on Domestic and Sexual Violence (NCDSV)

2009

This two-part article written by the director of the NCDSV explores the military and civilian challenges presented by domestic violence and behavior that is more often associated with PTSD or TBI, whether attributable to experiences in a military setting or some other influence, such as being a victim of child abuse or sexual assault or from brain injury impacting the impulse control of the sufferer. Ms. Tucker offers recommendations for lawyers and judges as well as resources for intervention with the offender and support for the victims.

 

VETERANS TREATMENT COURTS

Veterans Treatment Courts: Analysis and Recommendations

($)

Frederick, A. (2014). Veterans Treatment Courts: Analysis and Recommendations. Law & Psychology Review, 38211-230.

This note examines the creation of veterans treatment courts, a type of problem-solving court specifically for veterans, as a response to the increasing number of incarcerated veterans in the United States. Specifically, this note explores the history and development of veterans treatment courts, the operation and key components of the program, and the impact of applying its methodology. It also identifies and responds to the common criticisms of the system. Finally, this note concludes by providing recommendations for applying the mentor aspect of the program to other problem-solving courts. [ABSTRACT FROM AUTHOR]

 

An inventory of VA involvement in Veterans courts, dockets and tracks

Jim McGuire, PhD; Sean Clark, JD; Jessica Blue-Howells, LCSW; Cedric Coe, MAFO

VA Veterans Justice Programs

February 7, 2013

 

Catch, Treat, and Release: Veteran Treatment Courts Address the Challenges of Returning Home.

($)

Slattery, M., Dugger, M. T., Lamb, T. A., & Williams, L. (2013). Catch, Treat, and Release: Veteran Treatment Courts Address the Challenges of Returning Home. Substance Use & Misuse, 48(10), 922-932. doi:10.3109/10826084.2013.797468

After a decade of war, there is a great need for treatment and alternatives to incarceration for justice-involved veterans. U.S. military service members are returning from combat with substantial mental health challenges, which increase the potential for justice involvement. Veteran Treatment Courts are starting across the nation to meet this need for therapeutic justice. These problem solving courts provide access to treatment and motivation for engagement. Preliminary evidence from a Substance Abuse and Mental Health Services Administration-funded evaluation suggests that significant improvements in posttraumatic stress disorder and substance use are just a few of the positive outcomes that these courts may help veterans achieve. [ABSTRACT FROM AUTHOR]

 

Critical concerns in Iraq/Afghanistan war veteran-forensic interface: Veterans treatment court as diversion in rural communities.

Smee, D. E., McGuire, J., Garrick, T., Sreenivasan, S., Dow, D., & Woehl, D. (2013). Critical concerns in Iraq/Afghanistan war veteran-forensic interface: Veterans treatment court as diversion in rural communities. Journal Of The American Academy Of Psychiatry And The Law, 41(2), 256-262.

The veteran-forensic interface is an emerging area of relevance to forensic clinicians assessing or treating returning Iraq and Afghanistan war veterans facing criminal sanctions. Veterans’ Treatment Court (VTC) represents a recent diversion mechanism for low-level offenses that is based on a collaborative justice model. Thirty-nine percent of veterans who served in Iraq or Afghanistan and receiving VA services reside in rural areas. Rural veterans facing criminal justice charges may be at a disadvantage due to limited access to forensic psychiatrists with relevant expertise in providing veterans services for diversion. Therefore, widening the pool of forensic clinicians who have such expertise, as well as knowledge of the signature wounds of the wars as related to aggression and reckless behavior is necessary. This article presents an overview of VTCs and discusses the role of forensic clinicians as stakeholders in this process.

 

Veterans Courts: Early Outcomes and Key Indicators for Success

Holbrook, J. & Anderson, S. (2011). Veterans Courts: Early outcomes and key indicators for success. Social Science Research Network. Retrieved from http://ssrn.com/abstract=1912655

The growing trend within the judicial, treatment, and advocacy communities toward specialized courts for military veterans raises important questions about the effectiveness of such courts in rehabilitating veterans. Both principally and practically, veterans courts observers may take opposing positions regarding the appropriateness and effectiveness of placing veterans in a specialized, treatment-based court program simply because of their military service. This chapter explores these challenging issues in two parts. First, we undertake a discussion of first principle concerns related to veterans courts by reviewing research studies examining the link between veterans and criminal misconduct. The return of 1.6 million veterans from the wars in Iraq and Afghanistan has re-ignited the still unsettled controversy over whether veterans suffering from combat trauma are more likely than their non-veteran counterparts to commit criminal misconduct after returning home. While firm conclusions may be difficult (and unpopular) to draw, the issue warrants attention in any serious discussion about the merits and best practices of veterans court programs. Second, we present early findings from an assessment we conducted of the practices, procedures, and participant populations of certain veterans courts operating as of March 2011. Of the 53 courts invited to participate, 14 provided a response by completing either an online or paper survey. Of these, seven submitted sample policies and procedures, participant contracts, plea agreements, and mentor guidelines for our review. Drawing on these courts’ common practices and procedures, we identify key operational components courts should consider in implementing veterans court programs. We also conclude that veterans court outcomes, at least at present, appear at least as favorable as those of other specialized treatment courts.

 

The Battle on the Home Front: Special Courts Turn to Vets to Help Other Vets

William H. McMichael

November 2011

 

Veterans’ Courts and Criminal Responsibility: A Problem Solving History & Approach to the Liminality of Combat Trauma

Holbrook, Justin G. (2010). Veterans’ Courts and Criminal Responsibility: A Problem Solving History & Approach to the Liminality of Combat Trauma. Social Science Research Network. Retrieved from http://ssrn.com/abstract=1706829

In September 2010, a federal judge dismissed a criminal case involving a veteran accused of assaulting a federal police officer to allow the case to be heard by the Buffalo Veterans Treatment Court, a division of Buffalo City Court. For those involved in veterans’ advocacy and treatment, the case is significant for a number of reasons. First, it is the first criminal case nationwide to be transferred from federal court to a local veterans treatment court where the goal is to treat - rather than simply punish - those facing the liminal effects of military combat. Second, the case reignites the still unsettled controversy over whether problem-solving courts generally, and veterans courts specifically, unfairly shift the focus of justice away from the retributive interests of victims to the rehabilitative interests of perpetrators. Third, the case serves as a signal reminder to all justice system stakeholders, including parties, judges, attorneys, and treatment professionals, of the potential benefits of sidestepping courtroom adversity in favor of a coordinated effort that seeks to ameliorate victim concerns while advancing treatment opportunities for veterans suffering from combat-related trauma. This chapter explores these issues in light of the history of combat-related trauma and the development of veterans’ treatment courts around the country.

 

Coming Home: Accommodating the Special Needs of Military Veterans to the Criminal Justice System

Hawkins, M. D. (2010). Coming Home: Accommodating the Special Needs of Military Veterans to the Criminal Justice System. Ohio State Journal Of Criminal Law, 7(2), 563-573.

Large numbers of Iraq and Afghanistan war veterans are returning home with serious mental and emotional problems. In response to their impact on the criminal justice system, several jurisdictions have established veterans courts. Patterned after the early intervention and intensive supervision protocols of drug courts, these courts are designed to address the particular needs of these veterans. Focusing on nonviolent offenses and relying on a treatment rather than punishment model, early reports suggest the efforts are working to address the profound stress many veterans have experienced and the difficult adjustment to civilian life they face when returning home. [ABSTRACT FROM AUTHOR]

 

Should Problem Solving Courts be Solution-Focused Courts?

King, Michael S., Should Problem Solving Courts be Solution-Focused Courts? (December 13, 2010). Revista Juridica Universidad de Puerto Rico, Forthcoming; Monash University Faculty of Law Legal Studies Research Paper No. 2010/15.

Drug courts, family violence courts, mental health courts, community courts and variations of these courts have commonly been considered to be problem-solving courts. Implicit in the concept of and literature on these courts is the idea that it is the court that solves participants’ problems, often with the assistance of a multi-disciplinary team. However behavioral science research suggests that positive behavioural change involves the individual’s own internal processes and actions, albeit often assisted by treatment and support services. Rather than seeking to solve participants’ problems, these courts should be taking a solution-focused approach, supporting participants’ own change processes and facilitating their involvement with treatment and support agencies as needed. Such an approach avoids coercion and paternalism, promotes participant involvement in decision making and problem-solving concerning their rehabilitation, uses persuasion and motivational interviewing techniques where appropriate and supports participant self-efficacy. This approach is more likely to promote long-lasting behavioral change than a problem-solving approach. However further research is needed concerning the efficacy of particular judicial processes in these courts.

 

EVIDENCE BASED TREATMENT

Meta-analysis of the efficacy of treatments for posttraumatic stress disorder

($)

Watts, B. V., Schnurr, P. P., Mayo, L., Young-Xu, Y., Weeks, W. B., & Friedman, M. J. (2013). Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. Journal of Clinical Psychiatry, 74(6), e541-e550. doi:http://dx.doi.org/10.4088/JCP.12r08225

OBJECTIVE: PTSD is an important mental health issue in terms of the number of people affected and the morbidity and functional impairment associated with the disorder. The purpose of this study was to examine the efficacy of all treatments for PTSD. DATA SOURCES: PubMed, MEDLINE, PILOTS, and PsycINFO databases were searched for randomized controlled clinical trials of any treatment for PTSD in adults published between January 1, 1980, and April 1, 2012, and written in the English language. The following search terms were used: "post-traumatic stress disorders", "posttraumatic stress disorder", "PTSD", "combat disorders", and "stress disorders, post-traumatic". STUDY SELECTION: Articles selected were those in which all subjects were adults with a diagnosis of PTSD based on DSM criteria and a valid PTSD symptom measure was reported. Other study characteristics were systematically collected. The sample consisted of 137 treatment comparisons drawn from 112 studies. RESULTS: Effective psychotherapies included cognitive therapy, exposure therapy, and eye movement desensitization and reprocessing (g = 1.63, 1.08, and 1.01, respectively). Effective pharmacotherapies included paroxetine, sertraline, fluoxetine, risperidone, topiramate, and venlafaxine (g = 0.74, 0.41, 0.43, 0.41, 1.20, and 0.48, respectively). For both psychotherapy and medication, studies with more women had larger effects and studies with more veterans had smaller effects. Psychotherapy studies with wait-list controls had larger effects than studies with active control comparisons. CONCLUSIONS: Our findings suggest that patients and providers have a variety of options for choosing an effective treatment for PTSD. Substantial differences in study design and study participant characteristics make identification of a single best treatment difficult. Not all medications or psychotherapies are effective. [Author Abstract]

 

Cognitive processing therapy for veterans with posttraumatic stress disorder: a comparison between outpatient and residential treatment

($)

Walter, K. H., Varkovitzky, R. L., Owens, G. P., Lewis, J., & Chard, K. M. (2014). Cognitive processing therapy for veterans with posttraumatic stress disorder: A comparison between outpatient and residential treatment. Journal of Consulting and Clinical Psychology, 82(4), 551-561. doi:http://dx.doi.org/10.1037/a0037075

OBJECTIVE: Across the Veterans Affairs (VA) Healthcare System, outpatient and residential posttraumatic stress disorder (PTSD) treatment programs are available to veterans of all ages and both genders; however, no research to date has compared these treatment options. This study compared veterans who received outpatient (n = 514) to those who received residential treatment (n = 478) within a VA specialty clinic on demographic and pretreatment symptom variables. Further, the study examined pre- to posttreatment symptom trajectories across the treatment programs. METHOD: All 992 veterans met diagnostic criteria for PTSD and attended at least 1 session of cognitive processing therapy (CPT) in either the outpatient or residential program. Bivariate analyses were utilized to investigate differences between samples on demographic variables and severity of pretreatment symptoms. Multilevel modeling (MLM) was used to investigate the change in symptomatology between the 2 samples from pre- to posttreatment. RESULTS: Analyses indicated that the samples differed on all demographic and pretreatment symptom variables, with residential patients reporting higher scores on all assessment measures. MLM results demonstrated that symptom scores improved for all veterans across time, with outpatients consistently reporting fewer symptoms at both time points. The time by program interaction was significant for PTSD-related symptom trajectories, but not for the depression-related symptom trajectory. CONCLUSION: This is the 1st study to compare pretreatment characteristics and treatment outcome between veterans receiving outpatient and residential PTSD treatment. Findings may help clinicians select appropriate care for their patients by identifying relevant pretreatment characteristics and generally informing expectations of treatment outcome. [Author Abstract]

 

Evaluating treatment of posttraumatic stress disorder with cognitive processing therapy and prolonged exposure therapy in a VHA specialty clinic

($)

Jeffreys, M., Reinfeld, C., Nair, P., Garcia, H., Mata-Galan, E., & Rentz, T. (2014). Evaluating treatment of posttraumatic stress disorder with cognitive processing therapy and prolonged exposure therapy in a VHA specialty clinic. Journal Of Anxiety Disorders, 28(1), 108-114. doi:10.1016/j.janxdis.2013.04.010

This retrospective chart review evaluates the effectiveness of manualized cognitive processing therapy (CPT) protocols (individual CPT, CPT group only, and CPT group and individual combined) and manualized prolonged exposure (PE) therapy on veterans' posttraumatic stress disorder (PTSD) symptoms in one Veterans Health Administration (VHA) specialty clinic. A total of 517 charts were reviewed, and analyses included 178 charts for CPT and 85 charts for PE. Results demonstrated CPT and PE to significantly reduce PTSD Checklist (PCL) scores. However, PE was significantly more effective than CPT after controlling for variables of age, service era, and ethnicity. Additional findings included different outcomes among CPT formats, decreased treatment dropouts for older veterans, and no significant differences in outcome between Hispanic and White veterans. Study limitations and future research directions are discussed. (Published by Elsevier Ltd.)

 

Changes in Implementation of Two Evidence-Based Psychotherapies for PTSD in VA Residential Treatment Programs: A National Investigation

Cook, J. M., Dinnen, S., Thompson, R., Simiola, V., & Schnurr, P. P. (2014). Changes in Implementation of Two Evidence-Based Psychotherapies for PTSD in VA Residential Treatment Programs: A National Investigation. Journal Of Traumatic Stress, 27(2), 137-143. doi:10.1002/jts.21902

There has been little investigation of the natural course of evidence-based treatments (EBTs) over time following the draw-down of initial implementation efforts. Thus, we undertook qualitative interviews with the providers at 38 U.S. Department of Veterans Affairs’ residential treatment programs for posttraumatic stress disorder (PTSD) to understand implementation and adaptation of 2 EBTs, prolonged exposure (PE), and cognitive processing therapy (CPT), at 2 time points over a 4-year period. The number of providers trained in the therapies and level of training improved over time. At baseline, of the 179 providers eligible per VA training requirements, 65 (36.4%) had received VA training in PE and 111 (62.0%) in CPT with 17 (9.5%) completing case consultation or becoming national trainers in both PE and CPT. By follow-up, of the increased number of 190 eligible providers, 87 (45.8%) had received VA training in PE and 135 (71.1%) in CPT, with 69 (36.3%) and 81 (42.6%) achieving certification, respectively. Twenty-two programs (57.9%) reported no change in PE use between baseline and follow-up, whereas 16 (42.1%) reported an increase. Twenty-four (63.2%) programs reported no change in their use of CPT between baseline and follow-up, 12 (31.6%) programs experienced an increase, and 2 (5.2%) programs experienced a decrease in use. A significant number of providers indicated that they made modifications to the manuals (e.g., tailoring, lengthening). Reasons for adaptations are discussed. The need to dedicate time and resources toward the implementation of EBTs is noted.

 

Use of Evidence-Based Treatment for Posttraumatic Stress Disorder in Army Behavioral Healthcare

($)

Wilk, J. E., West, J. C., Duffy, F. F., Herrell, R. K., Rae, D. S., & Hoge, C. W. (2013). Use of Evidence-Based Treatment for Posttraumatic Stress Disorder in Army Behavioral Healthcare. Psychiatry: Interpersonal & Biological Processes, 76(4), 336-348. doi:10.1521/psyc.2013.76.4.336

Objective: To identify the extent to which evidence-based psychotherapy (EBP) and psychopharmacologic treatments for posttraumatic stress disorder (PTSD) are provided to U.S. service members in routine practice, and the degree to which they are consistent with evidence-based treatment guidelines. Method: We surveyed the majority of Army behavioral health providers ( n = 2,310); surveys were obtained from 543 (26%). These clinicians reported clinical data on a total sample of 399 service member patients. Of these patients, 110 (28%) had a reported PTSD diagnosis. Data were weighted to account for sampling design and nonresponses. Results: Army providers reported 86% of patients with PTSD received evidence-based psychotherapy (EBP) for PTSD. As formal training hours in EBPs increased, reported use of EBPs significantly increased. Although EBPs for PTSD were reported to be widely used, clinicians who deliver EBP frequently reported not adhering to all core procedures recommended in treatment manuals; less than half reported using all the manualized core EBP techniques. Conclusions: Further research is necessary to understand why clinicians modify EBP treatments, and what impact this has on treatment outcomes. More data regarding the implications for treatment effectiveness and the role of clinical context, patient preferences, and clinical decision-making in adapting EBPs could help inform training efforts and the ways that these treatments may be better adapted for the military. [ABSTRACT FROM AUTHOR]

 

Concurrent Naltrexone and Prolonged Exposure Therapy for Patients With Comorbid Alcohol Dependence and PTSD A Randomized Clinical Trial

Foa, E. B., Yusko, D. A., McLean, C. P., Suvak, M. K., Bux Jr., D. A., Oslin, D., & ... Volpicelli, J. (2013). Concurrent Naltrexone and Prolonged Exposure Therapy for Patients With Comorbid Alcohol Dependence and PTSD A Randomized Clinical Trial. JAMA: Journal Of The American Medical Association, 310(5), 488-495. doi:10.1001/jama.2013.8268

IMPORTANCE Alcohol dependence comorbid with posttraumatic stress disorder (PTSD) has been found to be resistant to treatment. In addition, there is a concern that prolonged exposure therapy for PTSD may exacerbate alcohol use. OBJECTIVE To compare the efficacy of an evidence-based treatment for alcohol dependence (naltrexone) plus an evidence-based treatment for PTSD (prolonged exposure therapy), their combination, and supportive counseling. DESIGN, SETTING, AND PARTICIPANTS A single-blind, randomized clinical trial of 165 participants with PTSD and alcohol dependence conducted at the University of Pennsylvania and the Philadelphia Veterans Administration. Participant enrollment began on February 8, 2001, and ended on June 25,2009. Data collection was completed on August 12,2010. INTERVENTIONS Participants were randomly assigned to (1) prolonged exposure therapy plus naltrexone (100 mg/d), (2) prolonged exposure therapy plus pill placebo, (3) supportive counseling plus naltrexone (100 mg/d), or (4) supportive counseling plus pill placebo. Prolonged exposure therapy was composed of 12 weekly 90-minute sessions followed by 6 biweekly sessions. All participants received supportive counseling. MAIN OUTCOMES AND MEASURES The Timeline Follow-Back Interview and the PTSD Symptom Severity Interview were used to assess the percentage of days drinking alcohol and PTSD severity, respectively, and the Penn Alcohol Craving Scale was used to assess alcohol craving. Independent evaluations occurred prior to treatment (week 0), at posttreatment (week 24), and at 6 months after treatment discontinuation (week 52). RESULTS Participants in all 4 treatment groups had large reductions in the percentage of days drinking (mean change, -63.9% [95% CI, -73.6% to -54.2%] for prolonged exposure therapy plus naltrexone; -63.9% [95% CI, -73.9% to -53.8%] for prolonged exposure therapy plus placebo; -69.9% [95% CI, -78.7% to -61.2%] for supportive counseling plus naltrexone; and -61.0% [95% CI, -68.9% to -53.0%] for supportive counseling plus placebo). However, those who received naltrexone had lower percentages of days drinking than those who received placebo (mean difference, 7.93%; P = .008). There was also a reduction in PTSD symptoms in all 4 groups, but the main effect of prolonged exposure therapy was not statistically significant. Six months after the end of treatment, participants in all 4 groups had increases in percentage of days drinking. However, those in the prolonged exposure therapy plus naltrexone group had the smallest increases. CONCLUSIONS AND RELEVANCE In this study of patients with alcohol dependence and PTSD, naltrexone treatment resulted in a decrease in the percentage of days drinking. Prolonged exposure therapy was not associated with an exacerbation of alcohol use disorder. [ABSTRACT FROM AUTHOR]

 

Challenges and Successes in Dissemination of Evidence-Based Treatments for Posttraumatic Stress: Lessons Learned From Prolonged Exposure Therapy for PTSD.

($)

Foa, E. B., Gillihan, S. J., & Bryant, R. A. (2013). Challenges and Successes in Dissemination of Evidence-Based Treatments for Posttraumatic Stress: Lessons Learned From Prolonged Exposure Therapy for PTSD. Psychological Science In The Public Interest (Sage Publications Inc.), 14(2), 65-111. doi:10.1177/1529100612468841

Posttraumatic stress disorder (PTSD) poses monumental public health challenges because of its contribution to mental health, physical health, and both interpersonal and social problems. Recent military engagements in Iraq and Afghanistan and the multitude of resulting cases of PTSD have highlighted the public health significance of these conditions. There are now psychological treatments that can effectively treat most individuals with PTSD, including active duty military personnel, veterans, and civilians. We begin by reviewing the effectiveness of these treatments, with a focus on prolonged exposure (PE), a cognitive-behavioral therapy (CBT) for PTSD. Many studies conducted in independent research labs have demonstrated that PE is highly efficacious in treating PTSD across a wide range of trauma types, survivor characteristics, and cultures. Furthermore, therapists without prior CBT experience can readily learn and implement the treatment successfully. Despite the existence of highly effective treatments like PE, the majority of individuals with PTSD receive treatments of unknown efficacy. Thus, it is crucial to identify the barriers and challenges that must be addressed in order to promote the widespread dissemination of effective treatments for PTSD. In this review, we first discuss some of the major challenges, such as a professional culture that often is antagonistic to evidence-based treatments (EBTs), a lack of clinician training in EBTs, limited effectiveness of commonly used dissemination techniques, and the significant cost associated with effective dissemination models. Next, we review local, national, and international efforts to disseminate PE and similar treatments and illustrate the challenges and successes involved in promoting the adoption of EBTs in mental health systems. We then consider ways in which the barriers discussed earlier can be overcome, as well as the difficulties involved in effecting sustained organizational change in mental health systems. We also present examples of efforts to disseminate PE in developing countries and the attendant challenges when mental health systems are severely underdeveloped. Finally, we present future directions for the dissemination of EBTs for PTSD, including the use of newer technologies such as web-based therapy and telemedicine. We conclude by discussing the need for concerted action among multiple interacting systems in order to overcome existing barriers to dissemination and promote widespread access to effective treatment for PTSD. These systems include graduate training programs, government agencies, health insurers, professional organizations, healthcare delivery systems, clinical researchers, and public education systems like the media. Each of these entities can play a major role in reducing the personal suffering and public health burden associated with posttraumatic stress. [ABSTRACT FROM PUBLISHER]

 

The Veterans Health Administration’s Treatment of PTSD and Traumatic Brain Injury Among Recent Combat Veterans

A Congressional Budget Office Study

February 2012

 

Prolonged exposure therapy for combat-related posttraumatic stress disorder: Comparing outcomes for veterans of different wars.

($)

Yoder, M., Tuerk, P. W., Price, M., Grubaugh, A. L., Strachan, M., Myrick, H., & Acierno, R. (2012). Prolonged exposure therapy for combat-related posttraumatic stress disorder: Comparing outcomes for veterans of different wars. Psychological Services, 9(1), 16-25. doi:10.1037/a0026279

There is significant support for exposure therapy as an effective treatment for posttraumatic stress disorder (PTSD) across a variety of populations, including veterans; however, there is little empirical information regarding how veterans of different war theaters respond to exposure therapy. Accordingly, questions remain regarding therapy effectiveness for treatment of PTSD for veterans of different eras. Such questions have important implications for the dissemination of evidence based treatments, treatment development, and policy. The current study compared treatment outcomes across 112 veterans of the Vietnam War, the first Persian Gulf War, and the wars in Afghanistan and Iraq. All subjects were diagnosed with PTSD and enrolled in Prolonged Exposure (PE) treatment. Veterans from all three groups showed significant improvement in PTSD symptoms, with veterans from Vietnam and Afghanistan/Iraq responding similarly to treatment. Persian Gulf veterans did not respond to treatment at the same rate or to the same degree as veterans from the other two eras. Questions and issues regarding the effectiveness of evidence based treatment for veterans from different eras are discussed. (PsycINFO Database Record (c) 2013 APA, all rights reserved) (journal abstract)

 

Evidence-based screening, diagnosis, and treatment of substance use disorders among veterans and military service personnel

Hawkins, E. J., Grossbard, J., Benbow, J., Nacev, V., & Kivlahan, D. R. (2012). Evidence-based screening, diagnosis, and treatment of substance use disorders among veterans and military service personnel. Military Medicine, 177(8), 29-38.

Substance use disorders (SUDs) are among the most common and costly conditions in veterans and active duty military personnel, adversely affecting their health and occupational and personal functioning. The pervasive burden of SUD has been a continuing concern for the Department of Veterans Affairs (VA) and Department of Defense (DoD), particularly as large numbers of service members return from Operations Enduring and Iraqi Freedom. The VA and DoD have prioritized implementation of evidence - based practices and treatment services to enhance the recognition and management of SUD in general medical and SUD specialty-care settings. This article summarizes the clinical practice guidelines for identifying, diagnosing, and treating SUD in VA and DoD general medical and SUD specialty-care settings, highlights evidence - based pharmacotherapy and psychosocial interventions for managing SUD, and describes barriers to successful treatment of veterans and service members at risk for SUD in VA and DoD health care systems. [Author Abstract]

 

Use of an Integrated Therapy With Prolonged Exposure to Treat PTSD and Comorbid Alcohol Dependence in an Iraq Veteran

Back, S. E., Killeen, T., Foa, E. B., Santa Ana, E. J., Gros, D. F., & Brady, K. T. (2012). Use of an Integrated Therapy With Prolonged Exposure to Treat PTSD and Comorbid Alcohol Dependence in an Iraq Veteran. American Journal Of Psychiatry, 169(7), 688-691. doi:10.1176/appi.ajp.2011.11091433

The article presents a case study of a 25-year-old single Caucasian Marine veteran with post-traumatic stress disorder (PTSD) and comorbid alcohol dependence. Patient was treated with a substance use disorder psychotherapy called concurrent treatment of PTSD and substance use disorders using prolonged exposure (COPE). The article discusses PTSD and co-occurring substance use disorders, as well as the use of COPE in treating the condition.

 

Interventions for War-Related Posttraumatic Stress Disorder: Meeting Veterans Where They Are

($)

Hoge CW. Interventions for War-Related Posttraumatic Stress Disorder: Meeting Veterans Where They Are.(2011).  JAMA. 306(5):549-551. doi:10.1001/jama.2011.1096.

 

Evidence-based treatments for posttraumatic stress disorder in Operation Enduring Freedom and Operation Iraqi Freedom military personnel

($)

Rothbaum, B. O., Gerardi, M., Bradley, B., & Friedman, M. J. (2011). Evidence-based treatments for posttraumatic stress disorder in Operation Enduring Freedom and Operation Iraqi Freedom military personnel. In J. I. Ruzek, P. P. Schnurr, J. J. Vasterling, M. J. Friedman (Eds.), Caring for veterans with deployment-related stress disorders (pp. 215-239). Washington, DC, US: American Psychological Association. doi:10.1037/12323-010

Because PTSD had not been recognized as an official psychiatric disorder by the end of the Vietnam War, there were no routine assessments or recommended treatments for this disorder. In contrast, the U.S. Departments of Defense (DoD) and Veterans Affairs (VA) have instituted systematic and comprehensive screening protocols for PTSD, traumatic brain injury (TBI), depression, and substance abuse to provide Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans evidence-based treatments as soon as possible. There are now several published treatment guidelines for PTSD, including those from the International Society for Traumatic Stress Studies (Foa, Keane, Friedman, & Cohen, 2009), the United Kingdom’s National Institute for Clinical Excellence (2005), VA and DoD (2003), American Psychiatric Association (APA, 2004), Australian Centre for Posttraumatic Mental Health (2007), and a literature review, the Institute of Medicine (2008) report. In the pages that follow, we review the literature on these interventions, including representative studies only if the literature base is large. For a comprehensive review of almost all empirically supported treatments for PTSD, the reader is referred to Foa et al. (2009). (PsycINFO Database Record (c) 2012 APA, all rights reserved)

 

Dissemination of evidence-based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration

Karlin, B. E., Ruzek, J. I., Chard, K. M., Eftekhari, A., Monson, C. M., Hembree, E. A., & ... Foa, E. B. (2010). Dissemination of evidence-based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration. Journal Of Traumatic Stress, 23(6), 663-673. doi:10.1002/jts.20588

Unlike the post-Vietnam era, effective, specialized treatments for posttraumatic stress disorder (PTSD) now exist, although these treatments have not been widely available in clinical settings. The U.S. Department of Veterans Affairs (VA) is nationally disseminating 2 evidence-based psychotherapies for PTSD throughout the VA health care system. The VA has developed national initiatives to train mental health staff in the delivery of Cognitive Processing Therapy (CPT) and Prolonged Exposure therapy (PE) and has implemented a variety of strategies to promote local implementation. In this article, the authors examine VA's national CPT and PE training initiatives and report initial patient, therapist, and system-level program evaluation results. Key issues, lessons learned, and next steps for maximizing impact and sustainability are also addressed. [ABSTRACT FROM AUTHOR]

 

Systematic Review and Meta-Analysis of Multiple-Session Early Interventions Following Traumatic Events

Roberts, N. P., Kitchiner, N. J., Kenardy, J., & Bisson, J. I. (2009). Systematic review and meta-analysis of multiple-session early interventions following traumatic events. The American Journal Of Psychiatry, 166(3), 293-301. doi:10.1176/appi.ajp.2008.08040590

Objective: The authors sought to determine the efficacy of multiple-session psychological interventions to prevent and treat traumatic stress symptoms beginning within 3 months of a traumatic event. Method: Nine computerized databases were searched, and manual searches were conducted of reference lists of selected articles as well as two journals. In addition, key researchers in the field were contacted to determine whether they were aware of other relevant studies. The reviewers identified randomized controlled trials of multiple-session psychological treatments aimed at preventing or reducing traumatic stress symptoms in individuals within 3 months of exposure to a traumatic event. Details of the studies were independently extracted by two reviewers, and outcome data were entered into the Review Manager software package. Quality assessment was also conducted by two researchers independently. Results: Twenty-five studies examining a range of interventions were identified. For treatment of individuals exposed to a trauma irrespective of their symptoms, there was no significant difference between any intervention and usual care. For treatment of traumatic stress symptoms irrespective of diagnosis, trauma-focused cognitive-behavioral therapy (CBT) was more effective than waiting list or supportive counseling conditions. The difference was greatest for treatment of acute stress disorder and acute posttraumatic stress disorder. Conclusions: Trauma-focused CBT within 3 months of a traumatic event appears to be effective for individuals with traumatic stress symptoms, especially those who meet the threshold for a clinical diagnosis. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

 

Early Intervention for Trauma: Where Are We and Where Do We Need to Go? A Commentary

($)

Litz, B. T. (2008), Early intervention for trauma: Where are we and where do we need to go? A commentary. Journal of Traumatic Stress, 21: 503–506. doi: 10.1002/jts.20373

In this commentary, the author underscores the importance of early intervention for trauma and describes the challenges that lie ahead for researchers, decision makers, and care providers. The author also provides a review of where things stand, briefly reviews psychological first aid strategies, and underscores where we need to go from here. Although the field has advanced considerably in the last decade or so, and there are compelling trials underway, there is much work that needs to be done, especially in terms of effectiveness and the task of integrating early intervention into various work cultures, such as the military.

 

Treatments for PTSD: Understanding the Evidence

PTSD Research Quarterly, National Center for PTSD

Summer 2008

 

Cognitive processing therapy for veterans with military-related posttraumatic stress disorder

($)

Monson, C.M., Schnurr, P.P., Resick, P,A., Friedman, M.J., Young-Xu, Y.; Stevens, S.P. (2006).  Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 74, 898-907. doi: 10.1037/0022-006X.74.5.898

Sixty veterans (54 men, 6 women) with chronic military-related posttraumatic stress disorder (PTSD) participated in a wait-list controlled trial of cognitive processing therapy (CPT). The overall dropout rate was 16.6% (20% from CPT, 13% from waiting list). Random regression analyses of the intention-to-treat sample revealed significant improvements in PTSD and comorbid symptoms in the CPT condition compared with the wait-list condition. Forty percent of the intention-to-treat sample receiving CPT did not meet criteria for a PTSD diagnosis, and 50% had a reliable change in their PTSD symptoms at posttreatment assessment. There was no relationship between PTSD disability status and outcomes. This trial provides some of the most encouraging results of PTSD treatment for veterans with chronic PTSD and supports increased use of cognitive- behavioral treatments in this population. (PsycINFO Database Record (c) 2013 APA, all rights reserved)

 

VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress

Department of Veterans Affairs & Department of Defense

2010

http://www.healthquality.va.gov/guidelines/MH/ptsd/

http://www.ptsd.va.gov/professional/treatment/overview/overview-treatment-research.asp

 

VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders (SUD)

Department of Veterans Affairs & Department of Defense

August 2009

http://www.healthquality.va.gov/guidelines/MH/sud/

 

VA/DoD Clinical Practice Guideline for the Management of Concussion/mild Traumatic Brain Injury (mTBI)

Department of Veterans Affairs & Department of Defense

April 2009

http://www.healthquality.va.gov/guidelines/Rehab/mtbi/

 

VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder (MDD)

Department of Veterans Affairs & Department of Defense

May 2009

http://www.healthquality.va.gov/guidelines/MH/mdd/

 

Comparative efficacy, speed, and adverse effects of three PTSD treatments: Exposure therapy, EMDR, and relaxation training

($)

Taylor, S., Thordarson, D.S., Maxfield, L., Fedoroff, I.C., Lovell, K., & Ogrodniczuk, J.S. (2003). Comparative efficacy, speed, and adverse effects of three PTSD treatments: Exposure therapy, EMDR, and relaxation training. Journal of Consulting and Clinical Psychology, 71, 330-338.

The authors examined the efficacy, speed, and incidence of symptom worsening for 3 treatments of posttraumatic stress disorder (PTSD): prolonged exposure, relaxation training, or eye movement desensitization and reprocessing (EMDR; N=60). Treatments did not differ in attrition, in the incidence of symptom worsening, or in their effects on numbing and hyperarousal symptoms. Compared with EMDR and relaxation training, exposure therapy (a) produced significantly larger reductions in avoidance and reexperiencing symptoms, (b) tended to be faster at reducing avoidance, and (c) tended to yield a greater proportion of participants who no longer met criteria for PTSD after treatment. EMDR and relaxation did not differ from one another in speed or efficacy. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

 

Does Early Psychological Intervention Promote Recovery From Posttraumatic Stress?

($)

Richard J. McNally, Richard A. Bryant, and Anke Ehlers

November 2003

In the wake of the terrorist attacks at the World Trade Center, more than 9,000 counselors went to New York City to offer aid to rescue workers, families, and direct victims of the violence of September 11, 2001. These mental health professionals assumed that many New Yorkers were at high risk for developing posttraumatic stress disorder (PTSD), and they hoped that their interventions would mitigate psychological distress and prevent the emergence of this syndrome. Typically developing in response to horrific, life-threatening events, such as combat, rape, and earthquakes, PTSD is characterized by reexperiencing symptoms (e.g., intrusive recollections of the trauma, nightmares), emotional numbing and avoidance of reminders of the trauma, and hyperarousal (e.g., exaggerated startle, difficulty sleeping). People vary widely in their vulnerability for developing PTSD in the wake of trauma. For example, higher cognitive ability and strong social support buffer people against PTSD, whereas a family or personal history of emotional disorder heightens risk, as does negative appraisal of one's stress reactions (e.g., as a sign of personal weakness) and dissociation during the trauma (e.g., feeling unreal or experiencing time slowing down). However, the vast majority of trauma survivors recover from initial posttrauma reactions without professional help. Accordingly, the efficacy of interventions designed to mitigate acute distress and prevent long-term psychopathology, such as PTSD, needs to be evaluated against the effects of natural recovery. The need for controlled evaluations of early interventions has only recently been widely acknowledged.

Psychological debriefing—the most widely used method—has undergone increasing empirical scrutiny, and the results have been disappointing. Although the majority of debriefed survivors describe the experience as helpful, there is no convincing evidence that debriefing reduces the incidence of PTSD, and some controlled studies suggest that it may impede natural recovery from trauma. Most studies show that individuals who receive debriefing fare no better than those who do not receive debriefing. Methodological limitations have complicated interpretation of the data, and an intense controversy has developed regarding how best to help people in the immediate wake of trauma.

Recent published recommendations suggest that individuals providing crisis intervention in the immediate aftermath of the event should carefully assess trauma survivors' needs and offer support as necessary, without forcing survivors to disclose their personal thoughts and feelings about the event. Providing information about the trauma and its consequences is also important. However, research evaluating the efficacy of such “psychological first aid” is needed.

Some researchers have developed early interventions to treat individuals who are already showing marked stress symptoms, and have tested methods of identifying those at risk for chronic PTSD. The single most important indicator of subsequent risk for chronic PTSD appears to be the severity or number of posttrauma symptoms from about 1 to 2 weeks after the event onward (provided that the event is over and that there is no ongoing threat).

Cognitive-behavioral treatments differ from crisis intervention (e.g., debriefing) in that they are delivered weeks or months after the trauma, and therefore constitute a form of psychotherapy, not immediate emotional first aid. Several controlled trials suggest that certain cognitive-behavioral therapy methods may reduce the incidence of PTSD among people exposed to traumatic events. These methods are more effective than either supportive counseling or no intervention.

In this monograph, we review risk factors for PTSD, research on psychological debriefing, recent recommendations for crisis intervention and the identification of individuals at risk of chronic PTSD, and research on early interventions based on cognitive-behavioral therapy. We close by placing the controversy regarding early aid for trauma survivors in its social, political, and economic context.

 

RECOMMENDED READING

 

The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research

January 12, 2017

Achilles in Vietnam: Combat Trauma and the Undoing of Character

Jonathan Shay, M.D., Ph.D.

1994

In this strikingly original and groundbreaking book, Dr. Shay examines the psychological devastation of war by comparing the soldiers of Homer’s Iliad with Vietnam veterans suffering from post-traumatic stress disorder.  Although the Iliad was written twenty-seven centuries ago it has much to teach about combat trauma, as do the more recent, compelling voices and experiences of Vietnam vets.

 

Odysseus in America: Combat Trauma and the Trials of Homecoming

Jonathan Shay, M.D., Ph.D.

2002

In this ambitious follow-up to Achilles in Vietnam, Dr. Jonathan Shay uses the Odyssey, the story of a soldier’s homecoming, to illuminate the pitfalls that trap many veterans on the road back to civilian life.  Seamlessly combining important psychological work and brilliant literary interpretation with an impassioned plea to renovate American military institutions, Shay deepens our understanding of both the combat veteran’s experience and one of the world’s greatest classics.

 

Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery

Since October 2001, approximately 1.64 million U.S. troops have been deployed for Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) in Afghanistan and Iraq. Early evidence suggests that the psychological toll of these deployments — many involving prolonged exposure to combat-related stress over multiple rotations — may be disproportionately high compared with the physical injuries of combat. In the face of mounting public concern over post-deployment health care issues confronting OEF/OIF veterans, several task forces, independent review groups, and a Presidential Commission have been convened to examine the care of the war wounded and make recommendations. Concerns have been most recently centered on two combat-related injuries in particular: post-traumatic stress disorder and traumatic brain injury. With the increasing incidence of suicide and suicide attempts among returning veterans, concern about depression is also on the rise.

The study discussed in this monograph focuses on post-traumatic stress disorder, major depression, and traumatic brain injury, not only because of current high-level policy interest but also because, unlike the physical wounds of war, these conditions are often invisible to the eye, remaining invisible to other servicemembers, family members, and society in general. All three conditions affect mood, thoughts, and behavior; yet these wounds often go unrecognized and unacknowledged. The effect of traumatic brain injury is still poorly understood, leaving a large gap in knowledge related to how extensive the problem is or how to address it.

RAND conducted a comprehensive study of the post-deployment health-related needs associated with these three conditions among OEF/OIF veterans, the health care system in place to meet those needs, gaps in the care system, and the costs associated with these conditions and with providing quality health care to all those in need. This monograph presents the results of our study, which should be of interest to mental health treatment providers; health policymakers, particularly those charged with caring for our nation’s veterans; and U.S. service men and women, their families, and the concerned public. All the research products from this study are available at http://veterans.rand.org.

Data collection for this study began in April 2007 and concluded in January 2008. Specific activities included a critical review of the extant literature on the prevalence of post-traumatic stress disorder, major depression, and traumatic brain injury and their short- and long-term consequences; a population-based survey of servicemembers and veterans who served in Afghanistan or Iraq to assess health status and symptoms, as well as utilization of and barriers to care; a review of existing programs to treat servicemembers and veterans with the three conditions; focus groups with military servicemembers and their spouses; and the development of a microsimulation model to forecast the economic costs of these conditions over time.

Among our recommendations is that effective treatments documented in the scientific literature — evidence-based care — are available for PTSD and major depression. Delivery of such care to all veterans with PTSD or major depression would pay for itself within two years, or even save money, by improving productivity and reducing medical and mortality costs. Such care may also be a cost-effective way to retain a ready and healthy military force for the future. However, to ensure that this care is delivered requires system-level changes across the Department of Defense, the Department of Veterans Affairs, and the U.S. health care system.

 

The Attorney’s Guide to Defending Veterans in Criminal Court

Eds. Brockton D. Hunter, Esq. and Ryan C. Else, Esq.

Introduction

For as long as warriors have returned from battle, some have brought their war home with them, bearing invisible wounds that haunt in the present.  These echoes of war—manifested in self-destructive, reckless, and violent behavior—reverberate through society, destroying not only the lives of these heroes, but their families and communities. 

A new generation of warriors is now returning home and there is good reason to believe more of them will bring their war home with them than ever before.  Unlike previous generations of warriors, this one is relatively small, yet it will have fought the two longest wars in our country’s history—simultaneously.  Without the draft we relied on in past wars, the burden of the fighting falls on fewer shoulders, with many veterans of this generation serving multiple combat tours.  We have also called on them to fight in the most hostile of environments—from the sweltering streets of Iraq, to the hostile high mountains of Afghanistan—facing fanatical enemies prepared to die for their cause.  Many of this generation will have survived combat injuries that would have killed them in the past, but will nonetheless bear the psychological scars of their brush with death.  Their modern combat training and conditioning ensured that they killed when called on to do so, yet did little to prepare them for the emotional and psychological costs of taking human life.

While this generation of returning veterans has been called on to serve and sacrifice like none before them, our society has never been asked to serve—or sacrifice—less.  Most Americans no longer follow news of the war in Afghanistan.  Even at the height of the war in Iraq, when media coverage was ubiquitous, we were allowed only, as one of our veteran clients refers to it, “a Clorox bleached version of the war,” carefully sanitized of all of its horror.  We were not even allowed to see images of flag-draped coffins unloaded from planes in the early years of the conflicts, out of concern it would impact our support for their continuance.  It worked.

This disconnect between our society and our wars was best symbolized by a piece of graffiti left by an anonymous Marine on a concrete blast wall in Ramadi, Iraq at the height of that war:

AMERICA IS NOT AT WAR

THE US MARINE CORPS IS AT WAR

AMERICA IS AT THE MALL

Our veteran clients commonly echo this sentiment, reporting to us that no one knows what they have seen—what they have done—and no one cares, too absorbed in our everyday lives to even begin to understand.  Whereas returning Vietnam veterans were notoriously spit on and called “baby killers,” this generation is largely invisible – feeding their isolation and hastening a downward spiral for many.

            The gulf between society and this generation of veterans will be increasingly dangerous in the coming years unless we find ways to bridge it.  But where do we start?  Author, Karl Marlantes, a Rhodes Scholar, who served as a Marine infantry officer in Vietnam and earned the Navy Cross, among many other medals, provides us with hard-won wisdom here:

"There is a correct way to welcome your warriors back.  Returning veterans don’t need ticker-tape parades or yellow ribbons stretching clear across Texas.  Cheering is inappropriate and immature.  Combat veterans, more than anyone else, know how much pain and evil have been wrought.  To cheer them for what they’ve just done would be like cheering the surgeon when he amputates a leg to save someone’s life.  It’s childish, and it’s demeaning to those who have fallen on both sides.  A quiet grateful handshake is what you give the surgeon, while you mourn the lost leg.  There should be parades, but they should be solemn processionals, rifles upside down, symbol of the sword sheathed once again.  They should be conducted with all the dignity of a military funeral, mourning for those lost on both sides, giving thanks for those returned…Veterans just need to be received back into their community, reintegrated with those they love, and thanked by the people who sent them." (fn 1)

The whole community must come together to bridge the gulf and properly welcome this generation of veterans.  When they stumble and fall into the criminal justice system, as we know many of them will, we in the defense bar have a additional, solemn role to play, in helping them up and bringing them the rest of the way home.

As we prepare to defend those who defended us, we must first recognize that we in the criminal defense bar share much in common with our veteran clients.  Like soldiers, our job is often gritty and thankless, our mission misunderstood by the general public.  Like soldiers, ours is a proud warrior culture, a tight and insular community with an esprit de corps not found in many other professions or areas of the law.  Above all, we, like our veteran clients, swore a sacred oath to defend the rights and freedoms that make our system of government so special.

As criminal defense lawyers and military veterans, Ryan Else and I set out to create a text that would empower our legal colleagues to passionately and skillfully defend our fellow veterans in criminal court.  To do so, we sought out some of the top experts from a wide range of disciplines to each contribute a chapter on their particular area of expertise.  The resulting 24 chapters are divided into four major sections.  Section I, Combat Trauma and Criminality:  the Historical and Sociological Connection, provides the big picture view and serves as the contextual foundation upon which the rest of the book is built.  Section II:  Understanding Invisible Injuries:  PTSD, TBI, and Related Substance Abuse, provides an overview of the current state of the rapidly evolving medical and psychological science on combat trauma.  Section III:  Special Considerations in the Attorney-Veteran Client Relationship provides military cultural competency to better understand your client and document his or her military service.  Section IV:  Defending the Combat Veteran in Criminal Court applies the historical, medical, and cultural content of the three preceding sections and translates it into concrete legal strategies, from case preparation to plea negotiation, trial, sentencing, and appeal.  The Appendix contains a wealth of practical resources, guides, chronologies, questionnaires, and samples.

            With proper preparation and execution, defending veterans can be among the most rewarding experiences a defense attorney can have.  We can simultaneously help repay our nation’s debt to these heroes for their service and sacrifice, uphold the special protections now afforded them in our justice system, and benefit society by helping turn them back into assets, not threats, to their communities.