Living with the War Inside: How Posttraumatic Stress Symptoms and Substance Use are Related to Violent and Nonviolent Charges among Veterans

Diana C. Bennett, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, and University of Michigan
David H. Morris, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, and University of Michigan
Minden B. Sexton, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, and University of Michigan
Erin E. Bonar, University of Michigan
Stephen T. Chermack, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, and University of Michigan

Substance misuse is prevalent among veterans entering the criminal justice system, and is related to recidivism. Research demonstrates that trauma exposure and posttraumatic stress (PTS) symptoms, which commonly co-occur with substance misuse, also increase the risk of legal involvement and recidivism. However, it is unclear whether the associations between trauma, PTS symptoms and violent and nonviolent crime may be conflated by substance use. The aim of the present study was to understand the association between PTS symptoms and criminal justice involvement (both violent and nonviolent crime) among substance-using veterans seeking Veterans Affairs (VA) specialty mental health care after accounting for substance use frequency and demographics including age, gender, and ethnicity. Further, this study examined whether specific clusters of PTS were associated with violent and nonviolent veteran offending. Participants included 697 veterans (52 women) aged 21 to 75 (M=47.49, SD=13.51) with a history of trauma exposure. Veterans self-reported past-month PTS symptoms, substance use, and lifetime legal charges. Logistic regression results indicated total PTS symptoms were associated with violent, but not nonviolent charges, above and beyond age, sex, race, cocaine use, and heavy alcohol use. Intrusion symptoms, in particular, were associated with violent charges. Results highlight the utility of examining PTS as a multifaceted construct and have implications for the assessment and treatment needs of justice-involved veterans. For example, the findings suggest that treatment needs appear to differ for those reporting violent or nonviolent offending, with a greater need for assessing and treating PTS for those involved with violent crime.

posttraumatic stress, legal involvement, violence, veterans

“Criminal behavior in veterans is a growing concern as estimates suggest as many as 181,500 veterans are incarcerated annually, more than half for violent offenses. Substance use disorders (SUDs) are particularly prevalent among individuals entering the criminal justice system compared with the general population, especially among military veterans. […] Strong evidence suggests substance use, particularly alcohol and cocaine use, is inextricably linked to higher risk of physical aggression and increased violent offending. However, other mental health and psychosocial problems (e.g., trauma exposure, PTS) also increase risk of perpetrating violence and criminal involvement among both military and veteran samples and civilians. Given that these other problems often co-occur with substance use problems, it is important to understand the impact they have on criminal offending in veterans who use substances.” (p. 135–136)

“Trauma exposure has been found to correspond with greater incidences of violence perpetration among veterans and civilians which may, in turn, contribute to criminal offending. [The] association between trauma exposure and violence perpetration also has been reported among those with SUDs. [The] acts of violence may result in criminal charges, followed by conviction and incarceration. Indeed, some studies have reported that a vast majority of criminal justice-involved adults report a history of trauma exposure.” (p. 136)

“However, other research has failed to find direct associations between trauma exposure and the perpetration of violence or criminal involvement. These discrepant findings have led some to propose that there are other intermediate mechanisms that account for the effect trauma exposure has on violence and criminal involvement. […] Trauma exposure indirectly increases the risk of antisocial behavior through the development of posttraumatic negative affect, including among veterans. While most individuals recover in the first few months following a trauma, a substantial number retain their PTS symptoms and develop posttraumatic stress disorder. PTS symptoms are divided into four clusters—intrusive recollections, avoidance, negative alterations in cognitions/mood, and arousal—and include features such as emotion dysregulation, anger/irritability, and difficulty sleeping. It is these symptoms, and not merely trauma exposure, that are believed to increase the likelihood of antisocial behavior (e.g., aggressive actions, impulsive/dysregulated behavior) and criminal involvement.” (p. 136)

“Substantial evidence supports the link PTS symptoms have with violence perpetration and criminal involvement and its mediating role in trauma’s effect on criminal offending. […] To date, no study has examined the association PTS symptoms have with criminal offending among substance-using veterans. PTSD and substance use problems commonly co-occur at high rates in the veteran population, resulting in more functional problems among veterans compared with each condition alone. It is possible that PTS symptoms have an additive effect on criminal offending in veterans with a history of trauma and recent substance use problems.” (p. 136)

“The present study aimed to fill a gap in the literature by examining how PTS symptoms correspond with higher occurrences of criminal offending in a sample of substance-using veterans with a history of trauma, military or nonmilitary related. We focused on violent (e.g., assault, rape) and nonviolent (e.g., forgery, theft) offenses separately as they have different interpersonal, societal, and legal implications. […] We hypothesized that given the correlation between PTSD and aggression, veterans reporting greater PTS symptoms would be more likely to have a violent legal charge.” (p. 136)

“An ancillary aim of the present study was to examine whether different PTS symptom clusters demonstrate unique associations with violent and nonviolent crimes. […] We anticipated that only the PTS symptom cluster of hyperarousal [such as anger and irritability, p. 136] would be associated with violent criminal offenses. No other a priori predictions were made about the differential associations PTS symptom clusters would have with criminal offending.” (p. 136–137)

“Data for the present study were collected as part of the screening process for a randomized controlled trial (RCT) of an intervention for substance use and violence prevention. Participants were recruited from a Midwestern Veterans Healthcare System (VHS) hospital and an associated VHS community-based outpatient clinic using posters, presentations, and clinician referrals.” (p. 137)

“Eight hundred thirty-nine veterans completed self-report measures during the screening process. Only those reporting any lifetime history of military (e.g., friendly or hostile incoming fire, military sexual trauma, prisoner of war) or nonmilitary (e.g., nonmilitary sexual trauma, vehicle accident, natural disaster) trauma exposure at screening (N = 719) were included in the present analyses. An additional 22 participants who had missing data for variables of interest were excluded, resulting in a final sample of 697 participants (7.5% women). The age range for this sample was 21 to 75 years old (M = 47.49, SD = 13.51), and the majority identified as White (73.0%), with 20.1% Black/African American, 3.4% Other/Multiracial, 2.2% Hispanic/Latino, 1.0% American Indian/Alaskan Native, and less than one percent Asian/Pacific Islander.” (p. 137)

The measures utilized in the study included: For violent and nonviolent legal charges—adapted items from the legal section of the Addiction Severity Index; For heavy drinking and cocaine use—modified open-ended items from the Substance Abuse Outcome Module; For combat exposure—single item drawn from the Traumatic Life Events Questionnaire; For PTS symptoms—the 17-item PTSD Checklist for Civilians.

“The current study is among the first to empirically investigate the differential relations of PTS symptoms with violent and nonviolent legal charges among veterans with substance use. We found greater PTS symptoms were associated with higher likelihood of violent legal charges even after adjusting for variance accounted for by other known risk factors for violence (e.g., age, race, substance use), and results were not attributable to combat exposure. As hypothesized, this pattern was specific to violent criminal offenses and did not generalize to charges for nonviolent offenses, marking a contribution to the field as the extant research to date has examined violent but not nonviolent crimes.” (p. 139)

“Among the symptoms clusters for PTSD, only the intrusion cluster was significantly associated with violent legal charges in multivariate analyses, and specifically, for each one unit increase in severity of intrusion symptoms reported, an individual’s likelihood of being charged with a violent crime increases by 7%. None of the symptom clusters were related to nonviolent legal charges. […] Our finding involving intrusion symptoms is contrary to our hypotheses based on prior research linking hyperarousal symptoms, in particular, to aggression and violence. […] Our current findings emphasizing intrusion appear to relate to general strain theory by identifying a link between the emotional distress and dysregulation present in PTS symptoms with antisocial behavior, but further research is needed to clarify how, over time, symptom clusters may operate together. […] Our results suggest that perhaps veterans with more severe intrusion symptoms are at greater risk of being charged with a violent criminal offense, or violent offending may be associated with increased frequency or intensity of intrusion symptoms.” (p. 139–140)

“The present study expands previous efforts attempting to disentangle the combined effects of PTS symptoms and substance use on violent behavior and legal involvement. Our findings suggest substance use, specifically cocaine use, is uniquely associated with the risk for nonviolent legal involvement, whereas PTS symptoms are uniquely related to violent charges. […] The lack of a significant relation between heavy drinking and legal charges in the current sample is surprising, given that this association is well-documented in previous literature. The null finding may be attributable to the restriction of range in our use of a substance-using sample, sample differences, or our use of a single item to measure past month heavy drinking. Additionally, it may be that the interaction of alcohol and other substances, such as cocaine, contribute to greater risk for legal charges. We also found that men were more likely to receive a violent charge, and ethnic minorities were more likely to receive any legal charge, consistent with previous research.” (p. 140)

“The current study included a large clinical sample that is highly generalizable to specialty treatment-seeking veterans with substance use issues and PTS symptoms, a common clinical presentation (although exclusion criteria, described above, does limit this generalizability). Results extend previous literature and aid our understanding of the intersection between substance use, PTS symptoms, and legal involvement among veterans. Further, examination of different types of legal charges and distinct clusters of PTS symptoms provide more detailed information than has been identified in the literature to date about the role of PTS symptoms above and beyond substance use in the association with violent legal charges.” (p. 141)

“One contribution of the current study is the identification of differential relations between PTS symptoms and violent and nonviolent legal charges. […] The current study offers one possible connection in observing that, among individuals with a history of trauma exposure, PTS symptoms may be related to engagement in violent legal offenses, in particular. This result, if replicated, would serve to help bridge the well-established findings of high rates of trauma exposure and PTS symptoms among incarcerated individuals to expand our understanding of how these factors are associated with offending. In our sample, participants reporting having served in a war zone were actually less likely to have legal charges, indicating that among veterans, combat exposure alone does not increase likelihood of legal charges, and rather, other variables such as PTS may be more important.” (p. 140)

“Our findings suggest substance use, specifically cocaine use, is associated with the risk for nonviolent legal involvement, whereas PTS symptoms are uniquely related to violent charges. Veterans with dual diagnoses of substance abuse disorders and PTSD, in particular, may be at escalated risk for legal involvement. […] Assessment of PTS symptoms among substance-using veterans is critical, and provision of evidence-based trauma-focused or substance use treatment for veterans with substance use problems may be invaluable in decreasing the likelihood of legal involvement, particularly violent crime. […] Trauma-informed treatment may be especially important for reducing violence and aggression among justice-involved veterans with PTS symptoms, and a one-size-fits-all approach to rehabilitation may not be appropriate.” (p. 140–141)

“The present findings yield potentially important implications for evaluating mental health problems among veterans involved in the criminal justice system. For instance, the Department of Veterans Affairs developed the Veterans Justice Outreach (VJO) program to advocate for justice-involved veterans with mental health care needs to be given the option to pursue clinically indicated treatment as an alternative to lengthy incarceration or other sanctions. VJO coordinators are currently available at all VA medical hospitals and facilitate case management services, psychiatric assessments, outreach, and liaison to mental health services for treatment planning and intervention. Through VJO programming, veterans are able to utilize treatment for SUD, PTSD, and other mental health concerns as part of their adjudication. Recent meta-analyses suggest concurrent trauma-focused treatment for PTSD with SUD treatment is effective in reducing PTS symptoms compared with treatment as usual. However, treatment initiation and retention among those with PTSD and SUD can be challenging. Results from the current study suggest that screening VJO-involved veterans for PTSD in addition to substance use, and offering evidence-based trauma-focused treatment, may be integral for successful diversion from further legal involvement.” (p. 141)

“Exclusion criteria included inability to read/speak English, inability to consent due to cognitive problems, current suicidal ideation, active psychosis, acute substance-induced cognitive impairment, current involvement in another intervention study, or residency outside the study catchment area. Those with legal guardians also were excluded.” (p. 137)

“Duration of the screening process was approximately 45–60 min, and participants were compensated for their time with gift cards totaling $10.” (p. 137)

“Although this study identified a connection between PTS and violent legal charges, it is important to note that most individuals with PTSD have not engaged in violent crime, and a diagnosis of PTSD alone is not indicative of elevated risk for violence. Rather, it is important for other risk and protective factors, such as substance use and engagement in violent crime, to be considered.” (p. 140)

“The findings should be considered in light of some study limitations. These data are cross-sectional in nature, and thus temporal associations and causality cannot be determined. We are limited in our interpretation of the data, given that we cannot determine the order of whether legal charges predate or follow military service and the development of PTS symptoms, and thus the direction of effects is unclear. […] In addition, the focus of the present study was to ascertain relationships specific to overall symptom severity and specific symptom clusters. As such, we did not utilize PCL-C cutoff scores indicative of probable PTSD. Therefore, our results may differ for veterans who meet full diagnostic criteria for PTSD. We also were limited in our measures of heavy drinking and cocaine use such that each were single-item only, which may help explain the weak or relative lack of findings involved with the SUD variables. […] Additionally, results may not generalize to all veterans, as the study was limited to those with recent substance use seeking specialty mental health care at the VA and without current suicidal ideation, psychosis or significant cognitive issues. […] Study data, including legal charges, were self-reported. […] Additional treatment studies are also needed to examine how clinical intervention can work to reduce recidivism among substance-using veterans, including case management, brief interventions targeting SUD, or trauma-focused treatment, and additional work is needed to determine the factors related to engagement and retention among this population.” (p. 141)

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