Toward an Integrated Theoretical Model of Risk ...

Journal of Human Behavior in the Social Environment

ISSN: 1091-1359 (Print) 1540-3556 (Online) Journal homepage: http://www.tandfonline.com/loi/whum20

Toward an Integrated Theoretical Model of Risk Factors for Post-Deployment PTSD and its Implications for Justice-Involved Veterans Olaoluwa Olusanya To cite this article: Olaoluwa Olusanya (2012) Toward an Integrated Theoretical Model of Risk Factors for Post-Deployment PTSD and its Implications for Justice-Involved Veterans, Journal of Human Behavior in the Social Environment, 22:6, 690-706, DOI: 10.1080/10911359.2012.664983 To link to this article: http://dx.doi.org/10.1080/10911359.2012.664983

Published online: 02 Aug 2012.

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Date: 02 November 2015, At: 05:11

Journal of Human Behavior in the Social Environment, 22:690–706, 2012 Copyright © Taylor & Francis Group, LLC ISSN: 1091-1359 print/1540-3556 online DOI: 10.1080/10911359.2012.664983

Toward an Integrated Theoretical Model of Risk Factors for Post-Deployment PTSD and its Implications for Justice-Involved Veterans

Downloaded by [Aberystwyth University] at 05:11 02 November 2015

OLAOLUWA OLUSANYA Department of Law and Criminology, Aberystwyth University, Ceredigion, Wales

At present, very little knowledge exists about individual differences in susceptibility to posttraumatic stress disorder (PTSD) after combat trauma. Two differing perspectives have emerged. Some researchers maintain that a distinct linear dose-response relationship exists between the severity of combat trauma and the later development of PTSD. Conversely, others have questioned whether differential exposure to combat alone is sufficient to explain differences in the prevalence of post-deployment PTSD. This debate has implications for military veteran offenders who suffer from PTSD. In this paper, I propose a cumulative stress model that posits that it is the particular combination of psychosocial factors and combat exposure that interact to predict the likelihood of developing and maintaining PTSD after deployment. Therefore, PTSD influences post-deployment offending and antisocial behavior through this mechanism. Finally, this paper will discuss implications for criminal justice policy and practice. KEYWORDS PTSD, antisocial behavior, veterans, individual differences, sensitisation

INTRODUCTION At present, very little knowledge exists about ‘‘why some service members exposed to combat develop PTSD symptoms whereas others do not’’ (Skopp Address correspondence to Olaoluwa Olusanya, Department of Law and Criminology, Aberystwyth University, Hugh Owen Building, Ceredigion SY23 3DY, Wales. E-mail: [email protected] 690


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et al., 2011, p. 277). Two differing perspectives have emerged. Some researchers maintain that a distinct linear dose-response relationship exists between the severity of combat trauma and the later development of posttraumatic stress disorder (PTSD). In other words, higher levels of combat exposure predict greater odds of having post-deployment PTSD symptoms (e.g., Buydens-Branchey, Noumair, & Branchey, 1990; O’Toole et al., 1996; Goldberg, True, Eisen, & Henderson, 1990; Roy-Bryne, Smith, Goldberg, Afari, & Buchwald, 2004). Conversely, others have questioned whether differential exposure to combat alone is sufficient to explain differences in the prevalence of post-deployment PTSD (Richardson, Frueh, & Acierni, 2010; Browne et al., 2007; Jones, Rona, Hooper, & Wessely, 2006; Friedman, Schnurr, & McDonach-Coyle, 1994; Killgore, Stetz, Castro, & Hoge, 2006). Furthermore, this debate has implications for military veteran offenders who suffer from PTSD. In this respect, studies demonstrating a dose-response or exposure-response relationship seem to have the upper hand at the moment. Practitioners and policy makers in the criminal justice system adhere to the view that many returning war veterans suffering from PTSD and who end up in the criminal justice system may well have ended up there because of PTSD arising from combat or combat-related situations (e.g., Cavanaugh, 2011). In addition, some researchers have proposed that PTSD arising from combat or combat-related situations mediates the relationship between combat and subsequent antisocial behavior (Byrne & Riggs, 1996; Orcutt, King, & King, 2003; Taft et al., 2007a, 2007b). This assumption has led to the view that programs or approaches that address micro-level risk factors such as Veterans Courts are likely to prevent or reduce the odds of veterans PTSD and post-deployment offending and antisocial behavior (e.g., Cavanaugh, 2011). In this paper, I contend that PTSD and post-deployment offending and antisocial behavior among veterans emanate from societal risk conditions rather than individual risk factors. Therefore, to the extent that current criminal justice policies focus almost exclusively on the individual, they are bound not to succeed because they fail to consider the social factors that contribute to the development and maintenance of PTSD among veterans (Manning & Marlowe, 1990, 83; Lowe, Rhodes, Zwiebach, & Chan, 2009; Bonanno, Galea, Bucciarelli, & Vlahov, 2007; Elliot & Pais, 2006; Galea, Tracy, Norris, & Coffey, 2008). In this respect, it should be pointed out that few considerations are given by treatment proponents to what role broader ecological contexts may play in the development and maintenance of PTSD symptoms (Gapen et al., 2011). Drawing on the examples of Vietnam, Iraq (Operation Iraqi Freedom), and Afghanistan (Operation Enduring Freedom) war veterans, I maintain that to fully understand the mechanisms underlying individual differences in susceptibility to post-deployment PTSD and the associated risk of post-


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discharge encounters with the criminal justice system, psychosocial factors (e.g., homelessness and unemployment; Gamache, Rosenheck, & Tessler, 2001, 485; Greenberg & Rosenheck, in press; Brewin, Andrews, & Valentine, 2000; Solomon & Milkulincer, 1990) should be taken into account along with combat exposure factors (e.g., severity and type of combat). In essence, I argue that the risk for PTSD increases with the cumulative number of traumatic incidents (Dougall, Herberman, Dalahanty, Inslicht, & Baum, 2000; King, King, Foy, Keane, & Fairbank, 1999; Schnurr, Lunney, & Sengupta, 2004). Therefore, subsequent traumatic events that are dissimilar to the stressors related to combat will put veterans at risk for PTSD after deployment, thereby exposing them to the associated risk of post-discharge encounters with the criminal justice system. Finally, I propose a cumulative stress model that posits that it is the particular combination of psychosocial factors and combat exposure that interact to predict the likelihood of developing and maintaining PTSD after deployment. Therefore, PTSD influences post-deployment offending and antisocial behavior through this mechanism. This paper will also discuss implications for criminal justice policy and practice.

RELATIONSHIP BETWEEN PTSD AND POST-DISCHARGE ENCOUNTERS WITH THE CRIMINAL JUSTICE SYSTEM PTSD has been known under various names throughout military history. For instance, during the Civil War, it was referred to as ‘‘soldier’s heart’’ (Schroder & Dawe, 2007). In World War I, it was called ‘‘combat fatigue,’’ and in World War II, soldiers who developed PTSD symptoms were said to be suffering from ‘‘battle fatigue,’’ (Doctor & Shiromoto, 2011, p. xiii). Then, in Vietnam, it reincarnated itself as ‘‘post-Vietnam syndrome’’ (Herbert & Forman, 2006). Presently, the term combat stress is used to describe the PTSD symptoms of veterans of the Gulf Wars and Afghanistan and Iraq conflicts (Doctor & Shiromoto, 2011, p. xiii). In this section, I examine the prevalence and psychological problems of veterans in U.S. correctional systems. In this respect, a great deal of attention is currently being given to the fact that many veterans are struggling to adjust to postwar civilian life. Many experience problems such as alcohol and substance abuse, homelessness, unemployment, and strained relationships. There is growing acceptance that the lack of commitment to seriously addressing these issues has resulted in many veterans’ ending up in the criminal justice system. Hence, the Department of Veterans Affairs and specialized veteran courts are intervention measures that have been established to remedy these difficulties. However, ‘‘[d]espite these developments,



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little research has assessed the prevalence of veterans in jails and prisons [or] the nature of their problems: : : : ’’ (White, Mulvey, Fox, & Choate, 2012, p. 260). Based on the data available so far, we can begin to put together a picture of the prevalence and psychological problems of veterans in U.S. correctional systems. The statistical evidence shows that ‘‘[a]pproximately 10,000 of the 71,000 inmates in the Federal Bureau of Prisons in 1992 were military service veterans, and approximately 10% of these incarcerated veterans likely suffered from combat-induced PTSD’’ (Hafemeister & Stockey, 2010, pp. 101– 102). Subsequent years have witnessed similar rates of incarceration, although there has been a general trend toward declining incarceration rates (Noonan & Mumola, 2007). A study conducted by Mumola (2000) on behalf of the U.S. Department of Justice found that ‘‘veterans accounted for 12% of all inmates in 1998, down from 21% in 1985’’ (Mumola, 2000, p. 1). In addition, a second follow-up study in 2007 (Noonan & Mumola) calculated that approximately 140,000 inmates (10% of state and federal prison populations) who were veterans were incarcerated in 2004. Furthermore, a number of studies have documented the psychological problems of veterans in U.S. correctional systems (e.g. White et al., 2012). For instance, the comprehensive National Vietnam Veteran Readjustment Study, published in 1988, revealed that 480,000 Vietnam veterans were diagnosable as having PTSD by the time the study was conducted, with almost half arrested or jailed at least once, 35% more than once, and 11.5% convicted of a felony (Kulka et al., 1990; Hafemeister & Stockey, 2010; Wilson & Zigelbaum, 1983; Pentland & Dwyer, 1985). Recently, White and his colleagues (2012), using interview data from 2,102 arrestees booked in Maricopa County (AZ) during 2009, examined the problems and prior experiences of arrested military veterans and compared veteran and non-veteran arrestees along a range of measures. Results of their study indicated that veterans comprise 6.3% of the arrestee population and that more than 50% of veterans report suffering from at least one combatrelated problem including physical injury (30%), PTSD (17%), other mental health problems (16%), and substance abuse (22%). In addition, multivariate analysis showed that veteran arrestees differed from non-veterans on a number of key measures, most notably more frequent arrests for violent offenses and greater use of crack cocaine and opiates. Finally, there is strong empirical support for a causal relationship between PTSD symptoms and post–military antisocial behavior (e.g., Hartl, Rosen, Drescher, Lee, & Gusman, 2005; McFall, Fontana, Raskind, & Rosenheck, 1999). In this regard, several studies have found a relationship between Veterans’ PTSD and increased risk-taking behavior (e.g., substance abuse; Begic & Jokic-Begic, 2001; Meisler, 1996) and even criminal conduct (e.g., Hartl et al., 2005; Taft et al., 2007a, 2007b).

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APPLYING A CUMULATIVE STRESS MODEL TO PREDICT INDIVIDUAL DIFFERENCES IN SUSCEPTIBILITY TO PTSD AFTER COMBAT TRAUMA AND THE ASSOCIATED RISK OF POST-DISCHARGE ENCOUNTERS WITH THE CRIMINAL JUSTICE SYSTEM In this section, I propose a cumulative stress model that posits that it is the particular combination of psychosocial factors and combat exposure that interact to predict the likelihood of developing and maintaining PTSD. Therefore, PTSD influences post-deployment offending and antisocial behavior through this mechanism. My intention is to reconcile the divergent views of the causal primacy of trauma-focused (combat exposure) versus psychosocial approaches (Miller & Rasmussen, 2010; Betancourt & Williams, 2008; Boothby, Strang, & Wessels, 2006) to understanding individual differences for susceptibility to PTSD symptoms after deployment as this has some bearing on post-deploymentrelated risk-taking and criminal behaviors. From a trauma-focused perspective, PTSD arising from combat or combat-related situations mediates the relationship between combat and subsequent antisocial behavior (Byrne & Riggs, 1996; Orcutt et al., 2003; Taft et al., 2007a, 2007b). In contrast, from a psychosocial perspective, factors such as social support (e.g., negative homecoming experiences) and additional stressful life events (e.g., homelessness and unemployment; Fontana, Rosenheck, & Horvath, 1997; Lee, Vaillant, Torrey, & Elder, 1995; Solomon & Mikulincer, 1990; Solomon, Mikulincer, & Flum, 1988) instead have causal primacy. In an effort to integrate these divergent theoretical perspectives, I argue that the risk for PTSD increases with the cumulative number of traumatic incidents (Dougall et al., 2000; King et al., 1999; Schnurr et al., 2004). It is worth emphasizing, however, that prior dissimilar trauma worsens chronic stress responding, whereas prior similar traumas do not (Dougall et al., 2000; McDermut, Haaha, & Kirk, 2000). Therefore, I maintain that dissimilarities between combat trauma and trauma rooted in various post-war factors such as negative homecoming experiences and additional stressful life events lead to sensitization rather than habituation effects (McDermut et al., 2000). Furthermore, the empirical evidence shows that individuals who encounter similar traumatic events frequently habituate to the stimuli and, therefore, they are more resistant to the psychological effects of traumatic incidents (Dougall et al., 2000; McDermut et al., 2000). In contrast, the cumulative effect of dissimilar traumatic event exposure will result in more posttraumatic stress symptoms (Dougall et al., 2000; McDermu et al., 2000). The findings of a recent study by Ben-Ezra, Essar, and Saar (2005) support the separation of similar from dissimilar traumatic event exposure. The researchers asked study participants to fill out a three-part questionnaire about



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their response to the traumatic event—the Hilton Hotel bombing in Sinai. The study compared rescue personnel with previous exposure to similar traumatic experiences and those experiencing their first exposure. Results showed that there was a significant difference in posttraumatic reactions between those in the previous traumatic exposure group and the novel exposure group. The researchers found that the novel exposure group exhibited more posttraumatic reactions than the veteran group who had been previously exposed to the same type of traumatic event. Finally, drawing on the examples of Vietnam, Iraq (Operation Iraqi Freedom), and Afghanistan (Operation Enduring Freedom) war veterans, I argue that to fully understand the mechanisms underlying individual differences in susceptibility to post-deployment PTSD and the associated risk of postdischarge encounters with the criminal justice system, psychosocial factors (e.g., homelessness and unemployment; Gamache et al, 2001; Greenberg & Rosenheck, in press; Brewin et al., 2000; Solomon & Milkulincer, 1990) should be taken into account along with combat exposure factors (e.g., severity and type of combat). The key assumptions underlying the proposed cumulative stress model are as follows: 1. PTSD increases the risk of incarceration (Hartl et al., 2005; Taft et al., 2007a, 2007b; Begic & Jokic-Begic, 2001; Meisler, 1996). 2. The fact that Vietnam War Veterans have higher incarceration rates (36%– 39% versus 4%; Noonan & Mumola, 2007) and PTSD prevalence rates (19%–30%; Dohwenred et al., 2006; Kulka et al., 1988 versus 7%–11%; Thomas et al., 2010) than Iraq and Afghanistan war veterans suggests that the differential exposure argument alone is insufficient to explain PTSD prevalence differences and the associated risk of offending. 3. It is more likely that post-deployment PTSD and the associated risk of post-discharge encounters with the criminal justice system are due to the combination of psychosocial factors and combat exposure rather than combat exposure alone.

Combat Exposure Studies have shown that the frequency and intensity of exposure to combat experiences is strongly associated with the risk of developing PTSD (American Psychiatric Association [APA], 1994; Turner, Turse, & Dohrenwend, 2007; Bremner, Southwick, & Charney, 1995; Hobfoll et al., 1991). For instance, Turner and his colleagues (2007) undertook further analysis of data on gender differences from the National Vietnam Veterans Readjustment Study and examined how differences in PTSD between male and female veterans might be specified by the amount and type of exposure to war-zone stress. The results of their study indicated that male elevations in PTSD are limited to men who served under circumstances of high probable severity of war-zone


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stress exposure. The study also showed that when prewar demographic differences are controlled, male veterans in low-exposure circumstances display a level of PTSD prevalence substantially lower than female veterans. In addition, studies that have explored racial differences among combat veterans with PTSD are also useful in this respect. For instance, Penk and his colleagues (1989) found that Black veterans who were exposed to heavy combat had more-severe PTSD symptoms than White veterans. Moreover, studies that statistically controlled for differences in trauma exposure eliminated PTSD differences between Blacks and Whites (Green, Grace, Lindy, & Leonard, 1990; Kulka et al., 1990). Finally, in terms of a dose-response relationship between trauma intensity and PTSD severity, some researchers have argued that soldiers deployed to Iraq faced greater risks than those deployed to Vietnam. For instance, according to Hafemeister & Stockey (2010), As during the Vietnam War, soldiers in Iraq and Afghanistan have faced surprise attacks and constant threats of bodily harm. But these wartime theaters also present some added novel threats that stem from changes in warfare technology. Military officers, among others, have commented on how the terrorist warfare being employed by the Iraqi insurgents is relatively unique. These reports indicate that the nature of the enemy’s action evolved: enemy forces moved away from small-unit infantry engagements toward more hit-and-run attacks that used improvised explosive devices, mortars, or rocket-propelled grenades : : : Compounding the stress stemming from the nature of the warfare in Iraq and Afghanistan has been the psychological toll associated with the ‘‘long and repeat deployments’’ of troops in these prolonged conflicts (p. 106).

However, both the fact that Vietnam War Veterans have higher PTSD prevalence rates than Iraq and Afghanistan war veterans (19%–30%; Dohwenred, 2006; Kulka et al., 1998 versus 7%–11%; Thomas et al., 2010) even though they faced less danger and the fact that personnel from different nations that faced high risk and significant exposure self-reported low rates of PTSD (Iversen et al., 2008; Unwin et al., 1999) suggest that the dose-response relationship between combat and PTSD is not always linear and therefore that that the development and course of PTSD is not solely determined by the features of the combat itself (Richardson et al., 2010; Hotopf et al., 2006; Iversen et al., 2008). In the next section, I consider additional explanatory variables.

Psychosocial Factors From the preceding analysis, it is quite evident that differential exposure to combat alone is insufficient for explaining individual differences in susceptibility to post-deployment PTSD and the associated risk of post-discharge en-



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counters with the criminal justice system and psychosocial factors (Richardson et al., 2010; Browne et al., 2007; Jones et al., 2006; Friedman et al., 1994; Killgore et al., 2006). In this section, I contend that combat exposure in combination with a variety of psychosocial factors contributes to post-deployment PTSD and the associated risk of post-discharge encounters with the criminal justice system. Specifically, I consider the following psychosocial factors: low social support including negative homecoming experiences and socioeconomic stressors such as poverty and homelessness (Fontana et al., 1997; Lee et al., 1995; Solomon & Mikulincer, 1990; Solomon et al., 1988). In relation to social support upon return from combat, it should be pointed out that ‘‘compared with research on pre-exposure factors : : : relatively few studies have examined the use of post exposure factors in PTSD’’ (Institute of Medicine, 2010, p. 49). Furthermore, the statistical evidence shows that the Vietnam War had low public support; whereas in the case of the most recent wars in Iraq and Afghanistan, though a majority of Americans supported both wars, polls indicate support is starting to wane (Milbank & Deane, 2005; see http://pewresearch.org/pubs/1349/support-fallsafghanistan-war-troop-removal). Nevertheless, both categories of veterans have received very different receptions (Friedman, 2004; Badkhen, 2007; Harris, 2007). In this respect, Harris observed that: ‘‘[i]n contrast to some reactions during the Vietnam war, veterans of Iraq and Afghanistan are almost universally regarded as returning heroes, even by staunch critics of the conflicts’’ (34; Settersten, 2006). In addition, several studies of Vietnam veterans have established a connection between lack of social support—that is, a buffer against reactions to stressful life events such as combat exposure, and PTSD (e.g., Benight & Bandura, 2004; Fontana & Rosenheck, 1994; Stretch, 1985). In this respect, Empirical surveys of both soldiers and Veterans Administration (VA) Mental Health Professionals have repeatedly identified social support upon return from Vietnam as a critical factor in the development of PTSD, often more critical than the intensity of the combat experienced or the social support received while in Vietnam (Manning & Marlowe, 1990, p. 83).

Moreover, in terms of socioeconomic stressors such as poverty and homelessness, the empirical evidence reveals that veterans traditionally comprise a high proportion of the homeless (Kanter, 1986, 336, n.35; Rosenheck et al., 1989) and that Vietnam veterans make up between 16% and 43% of all homeless veterans (Robertson, 1987). Results of more-recent studies show that post-Vietnam era veterans have the highest risk for homelessness (Gamache et al., 2001). In addition, it should be recalled that McNamara’s Project 100,000, which was initiated during U.S. involvement the Vietnam War, aggressively re-


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cruited underprivileged youths. McNamara labeled these youths the ‘‘subterranean poor,’’ as if they lived in caves (Macpherson, 1984). Thus, the vast majority of Vietnam-era draftees were poor, uneducated, and unemployed. Therefore, it is possible that the reason why Vietnam veterans make up a large percentage of all homeless veterans (Robertson, 1987) is simply that unlike their successors (Gulf War and Afghanistan veterans), many return to the same economic and social conditions that led to their enlistment in the military in the first place (Gamache et al., 2001; Greenberg & Rosenheck, in press). It is interesting to note, in this connection, that ‘‘[i]n studies that controlled for prewar statuses, the positive effects of veteran status on postwar income disappear or even turn negative’’ (Settersten, 2006, p. 21; Angrist, 1990; Angrist & Krueger, 1994). Finally, there exist a large number of studies offering empirical evidence in support of the view that homelessness and other negative social circumstances increase the risk for PTSD. For instance, several studies have reported elevated psychological distress, including levels of depression and anxiety, among people of low socioeconomic status (e.g., Lowe et al., 2009; Bonanno et al., 2007; Elliot & Pais, 2006; Galea et al., 2008).

Criminal Justice Policy Implications In terms of criminal justice implications, the primary difference between the trauma-focused (combat exposure) approach and the psychosocial approach (Miller & Rasmussen, 2010; Betancourt & Williams, 2008; Boothby et al., 2006) to understanding individual differences in susceptibility to postdeployment PTSD and the associated risk of post-discharge encounters with the criminal j ustice system is that the trauma-focused approached is based on the assumption that chronic PTSD indicates a need for special treatment (Donovan, Padin-Rivera, Dowd, & Blake, 1996; Prigerson, Maciejewski, & Rosenheck, 2002). In contrast, psychosocial advocates maintain that chronic PTSD is rooted in various factors, such as negative homecoming experiences and additional stressful life events (Fontana et al., 1997; Lee et al., 1995; Solomon & Mikulincer, 1990; Solomon et al., 1988). According to Miller and Rasmussen (2006), From a psychosocial viewpoint, altering those stressful conditions is likely to improve people’s mental health, while also fostering their inherent capacity to recover—with adequate social support and the passing of time—from the lingering effects of exposure to war-related violence and loss : : : Conversely, trauma-focused advocates believe that ameliorating symptoms of war-related trauma will not only improve mental health, but will also enable people to cope more effectively with ongoing environmental stressors. (p. 7; Betancourt & Williams, 2008; Boothby et al., 2006).



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Furthermore, at present, there is overwhelming support for the traumafocused (combat exposure) approach as evidenced by the rapid proliferation of Veterans Treatment Courts (VTCs) throughout the United States. Modeled after drug courts (Cavanaugh, 2011), VTCs ‘‘are directed at rehabilitating veterans and reducing recidivism via properly tailored counseling, drug and alcohol programs, and job placement programs that contemplate the veterans’ specific physical and emotional needs.’’ One worrying aspect, however, is that ‘‘[f]or those veterans who succeed in the program, their criminal charges are dropped; however, for those who fail, their jail sentences are imposed’’ (Cavanaugh, 2011; Ruggeri, 2009). Therefore, harsh treatment awaits those who do not succeed: ‘‘The hammer [you have] is that if these guys [do not] behave, they go back to jail: : : : That’s the ultimate accountability’’ (according to Rep. John Boozman as cited in Cavanaugh, 2011, note 90); ‘‘Should they waver from the straight and narrow, their sentence[s] [go] into effect’’ (statement by Nicholas Riccardi, as cited in Cavanaugh, 2011, note 91). However, the problem with this exclusive focus on the individual is that it fails to recognize the importance of stressful life events after war that have already been shown in the previous discussion to be significant predictors of post-deployment PTSD and associated risk behaviors among war veterans (Fontana & Rosenheck, 1994; Stretch, 1985). In this respect, it should be pointed out that the majority of studies assessing the impact of trauma exposure focuses only on factors at the individual level of analysis : : : despite increasing recognition of the importance of macro-level factors for understanding risk and resilience : : : Specifically, individual-level outcomes are not only dependent on individual factors, but also on larger contexts, such as the social and community environment (Gapen et al., 2011; Bronfenbrenner, 1979; Coulton & Korbin, 2007; Jones & Duncan, 1995; Ross & Mirowsky, 2001; Sampson & Groves, 1989).

Finally, the preceding viewpoint suggests that rehabilitation programs for veterans charged with criminal behaviors stemming from post-deployment PTSD will have at best a negligible impact on the groups they are intended to assist. It is also possible to argue that individual-level initiatives have the potential for negative rather than positive effects on veterans. It appears that policy makers have failed to learn lessons from the problems created by drug courts. In this respect, it should be pointed out that the implementation of drug courts has ‘‘[triggered] such massive net widening that they end up sending many more drug defendants to prison than traditional criminal courts ever did’’ (Gross, 2010, p. 162; Hoffman, 2002).

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CONCLUSION As is evident through the discussion in this paper, it is necessary to understand individual differences in susceptibility to post-deployment PTSD and the associated risk of post-discharge encounters with the criminal justice system among veterans as emanating from dissimilarities between combat trauma and trauma rooted in various post-war factors such as negative homecoming experiences and additional stressful life events. Thus, the interaction between dissimilar traumatic events leads to sensitization rather than habituation effects (Dougall et al., 2000; McDermut et al., 2000). At present, policy makers and practitioners in the criminal justice system appear to be guided by the assumption that combat exposure alone explains individual differences in susceptibility to post-deployment PTSD and the associated risk of post-discharge encounters with the criminal justice system. Viewed from this perspective, a treatment approach is the only effective means of reducing the chance that further offences will be committed by veterans. In addition, combat-related PTSD and individual deficiencies are viewed as leading causes of homelessness and unemployment among veterans (Cavanaugh, 2011), despite the fact that in reality it is psychosocial factors such as lack of social support, homelessness, and unemployment in combination with combat exposure that predict the likelihood of developing and maintaining PTSD after deployment. Roisman (2005) made the following relevant statement in this respect: The United States government’s current housing programs for veterans fail to meet the needs of most veterans, the deficiency being starkest with respect to the more than half million veterans who suffer literal homelessness each year. Despite all the current rhetoric of ‘‘supporting our troops’’ and aiding veterans and their dependents and survivors, most veterans today, including most veterans with service-connected and other disabilities, receive no housing assistance whatsoever from the federal government. This is hardly a model of gratitude for the wealthiest, most powerful nation on earth; it can and should be corrected (p. 176).

Finally, at present few considerations are given by treatment proponents to what role broader ecological contexts may play in the development and maintenance of PTSD symptoms (Gapen et al., 2011). However, to the extent that current criminal justice policies focus almost exclusively on combat-related PTSD and individual deficiencies, they are bound not to succeed. Trying to shift the entire responsibility for alcohol or substance abuse, homelessness, unemployment, and mental health issues onto war veterans is clearly an inadequate response. This blames the victim rather than addressing the complexities of the social circumstances that complicate and prolong PTSD problems upon return from war. Effective policies must, therefore, situate PTSD-related criminal behavior within a larger context of


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social and political marginalization that dominates the lives of most veterans who now find themselves in the criminal justice system.


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