Posttraumatic Stress Disorder and Justice Involvement Among Military Veterans
Emmeline N. Taylor, BS, Mandy D. Owens, PhD, Amia Nash, MS, Andrea Finlay, PhD
July 17, 2020
Military veterans are at an increased risk for posttraumatic stress disorder (PTSD) due to combat exposure and other traumatic military experiences (Xue et al, 2015). PTSD has been linked with criminal justice involvement including being arrested or incarcerated (Anderson, Geier, & Cahill, 2016; Elbogen et al., 2012; Sherman, Fostick, & Zohar, 2014). Understanding the association between PTSD and criminal justice involvement, as well as the strengths and limitations of the studies examining this association, will aid clinicians and healthcare systems that serve military veterans.
To better understand this association, researchers systematically reviewed and analyzed published studies that examined veterans (a) with and without PTSD and (b) their criminal justice involvement, including current or past arrests, incarceration, or criminal charges. Five databases were searched for a larger scoping review, and observational studies that assessed PTSD and criminal justice involvement were identified from the scoping review database (N = 191). Ten studies were selected for final inclusion with sample sizes ranging from 61 to over 36,000 veterans. Countries represented in the studies included the United States, the United Kingdom, and Israel. Meta-analyses were conducted, pooling odds ratios, and the main outcomes were criminal justice involvement (e.g., documentation of arrest) and PTSD (e.g., PTSD assessment score indicating probable PTSD). Additionally, we examined study quality, publication year, sample size, proportion of White veterans compared to all other races/ethnicities combined, and proportion of male veterans compared to female veterans as moderators of the link between PTSD and criminal justice involvement.
A primary finding of this study was that veterans with PTSD had higher odds of criminal justice involvement compared to veterans without PTSD. Only sample size was found to significantly moderate the association between PTSD and criminal justice involvement, such that larger sample sizes yielded a larger association and accounted for some of the heterogeneity. The findings of this meta-analysis support an association between PTSD and criminal justice involvement among military veterans. Results also highlight an important need for clinicians to screen for and address PTSD among military veterans to potentially reduce these veterans’ risk of criminal justice involvement. Trauma-informed care and trauma-specific cognitive behavioral interventions are promising treatments to address the association between PTSD and criminal justice involvement among veterans. Additionally, early screening for PTSD in healthcare and criminal justice settings, as well as interventions such as Veterans Treatment Courts, may help to connect justice-involved veterans with PTSD to the treatments they need while simultaneously breaking the link to criminal justice involvement. For this study, we conducted an extensive literature search and an in-depth analysis of relevant studies, but it is important to note the small sample size as a limitation. Further, the direction of a causal association between PTSD and criminal justice involvement cannot be determined by the results of this study. Studies lacked attention to specific PTSD symptoms, other mental health conditions (e.g., antisocial personality disorder), crime type, and timing of trauma and justice involvement.
The mechanism by which other factors may interplay with PTSD and the risk of criminal justice involvement should be examined in future studies. It is unclear what may be driving the association between PTSD and criminal justice involvement. Assessment of the timing of trauma exposure and involvement in the justice system is necessary to elucidate the directionality of the association between PTSD and criminal justice involvement. Grounding future research on PTSD and criminal justice involvement in theoretical frameworks could help clarify pathways between PTSD and criminal justice involvement. This study highlights the importance for more research on PTSD and criminal justice involvement among veterans. Given the high rates of both PTSD and criminal justice involvement among veterans, better understanding these factors will help to improve prevention and treatment interventions for this population.
References
Anderson, R. E., Geier, T. J., & Cahill, S. P. (2016). Epidemiological associations between posttraumatic stress disorder and incarceration in the National Survey of American Life. Criminal Behaviour & Mental Health, 26, 110–123. https://doi.org/10.1002/cbm.1951
Egger, M., Smith, G. D., Schneider, M., & Minder, C. (1997). Bias in meta-analysis detected by a simple, graphical test. BMJ, 315(7109), 629–634. https://doi.org/10.1136/bmj.315.7109.629
Elbogen, E. B., Johnson, S. C., Newton, V. M., Straits-Troster, K., Vasterling, J. J., Wagner, H. R., & 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, 1097–1102. https://doi.org/10.1037/a0029967
Light, R. J., & Pillemer, D. B. (1984). Summing up: The science of reviewing research. Cambridge, MA: Harvard University Press.
Sherman, S., Fostick, L., & Zohar, J. (2014). Comparison of criminal activity between Israeli veterans with and without PTSD. Depression & Anxiety, 31, 143–149. https://doi.org/10.1002/da.22161
Viechtbauer, W. (2010). Conducting meta-analyses in R with the metafor package. Journal of Statistical Software, 36, 48. https://doi.org/10.18637/jss.v036.i03
Xue, C., Ge, Y., Tang, B., Liu, Y., Kang, P., Wang, M., & Zhang, L. (2015). A meta-analysis of risk factors for combat-related PTSD among military personnel and veterans. PLoS One, 10(3), e0120270. https://doi.org/10.1371/journal.pone.0120270
Reference Article
Taylor, E.N., Timko, C., Nash, A., Owens, M.D., Harris, A.H. and Finlay, A.K. (2020), Posttraumatic Stress Disorder and Justice Involvement Among Military Veterans: A Systematic Review and Meta‐Analysis. JOURNAL OF TRAUMATIC STRESS. doi:10.1002/jts.22526
Questions for Discussion
- What information do we need to better understand the relationship between PTSD and criminal justice involvement?
- What clinical interventions might you use to address PTSD and trauma in justice-involved populations?
- What system-level intervention or prevention strategies could be implemented to help break the association between PTSD and justice involvement?
About the Authors
Emmeline N. Taylor, BS, is a PhD student in clinical psychology with an emphasis in trauma at the University of Colorado Colorado Springs. She also works part-time for the U.S. Department of Veterans Affairs Center for Innovation to Implementation. Her research focuses on thriving after trauma, emotion regulation in trauma survivors, and applying nonlinear science to phenomena in trauma recovery.
Mandy D. Owens, PhD, is a clinical psychologist and research scientist at the Alcohol & Drug Abuse Institute at the University of Washington. Her research and clinical work focus on treatments for individuals with a substance use disorder, particularly those involved with the criminal legal system.
Amia Nash, MS, is a Doctor of Public Health student at the University of California, Berkeley. Her research focuses on youth-led participatory action research with underrepresented youth populations.
Andrea Finlay, PhD, is a Research Health Scientist at the Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, and an Affiliated Researcher at the National Center on Homelessness Among Veterans, U.S. Department of Veterans Affairs. Her research focuses on identifying and addressing gaps in access, engagement, and quality of health care among justice-involved Veterans.