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Effective Strategies for Working with Justice-Involved Veterans with Behavioral Health Needs


September 1, 2011

Larke N. Huang, Ph.D.
David Morrissette, Ph.D.
Henry J. Steadman, Ph.D.
Nicholas Meyer, B.A.
Jim Tackett, B.A.

Slide 1.
HENRY J. STEADMAN: Well, good afternoon everyone and welcome to the webinar on "Effective Strategies for Working with Veterans with Behavioral Health Needs." We have a very diverse group of people participating today both presenting and listening where you have veterans, active military, family members, consumers, advocates, service providers, policymakers, administrators and researchers. And we really welcome you all.
I would mention, as we begin, and we'll give you this on the last slide today that the event is being recorded and will be archived on the Substance Abuse in Mental Health Services Administration, SAMHSA Co-Occurring Disorders Website and we'll give you that address at the end and we'll also email it to everyone who registered for this after the seminar.

Slide 2.
HENRY J. STEADMAN: My name is Hank Steadman. I'm the President of Policy Research Associates. We are a contractor with SAMHSA for the National Gain Center and for the SAMHSA Military Family Strategic Initiative Service Systems Development Program.   And I will be the moderator for today's presentation.
The seminar is sponsored by the Substance Abuse Mental Health Services Administration, known to many of you by the acronym SAMHSA.

Slide 3.
HENRY J. STEADMAN: For the presentation we brought together people who had been working with veterans in the justice system to meet the behavioral health needs. We have a full agenda and we're very pleased today to have Dr. Larke Huang and David Morrissette here representing SAMHSA.
Before we actually get it to the presentation, I'd like to mention a couple of important logistics.

Slide 4.
HENRY J. STEADMAN: The first is that you may submit questions at anytime through the questions box that is a part of the menu on the right side of the screen that you'll have on your computers. If you type your questions and send it to the organizers, they'll be recorded as they come in over the course of the presentation. We're hoping to have at least 15 or maybe 20 minutes at the end by the presenters or the two SAMHSA staff to answer any questions that you posted over the course of it. All of you will get a follow up email, if you have registered, with an evaluation on and if you would take the time and it doesn't very long to complete that, it helps us doing future webinars, we would appreciate that.

Okay, so we can start with the content.

Slide 5.
HENRY J. STEADMAN: I'd like to introduce the two SAMHSA representatives, Dr. Larke Huang and Dave Morrissette who'll provide the introductions in the context of today's presentation. Larke is a senior advisor in the Office of Policy Planning and Innovation at SAMHSA. She's also the lead for the SAMHSA Strategic Initiative on Trauma and Justice and she is the director of SAMHSA's Office of Behavioral Health Equity.

Dave is a Social Science Analyst at SAMHSA. He's also a Captain in the U.S. Public Health Service. At SAMHSA, he directs the initiative that funds 13 states to provide trauma integrated behavioral health services for veterans involved in the criminal justice system and we're honored to have both Larke and Dave to open today's webinar. And with that, let me turn it over to you, Larke.

LARKE HUANG: Okay. Thank you very much, Hank. I'm pleased to be part of this webinar and to welcome you on behalf of SAMHSA and our Co-Occurring Disorders Integration and Innovation initiative. As Hank mentioned, one of our key strategic initiatives at SAMHSA is what we refer to as trauma and justice. Trauma is considered one of our major areas of programming, planning, and initiatives now. We arrived at that as a key priority as we understand more about the central role of trauma in both mental and substance use disorders. And when we're referring to trauma, we're looking at a range of types of trauma events whether it's abuse, sexual abuse, neglect, trauma emerging from disasters, war and military related trauma. We're using it in a very broad frame here. We also know that there are high rates of trauma and trauma histories among people with behavioral problems and people in the justice system. We know that in the justice system, you know, there are increasing numbers of people that have mental health and substance use issues, so that's why we have placed it as one of our top priorities and strategic areas within SAMHSA.

Slide 6.
LARKE HUANG: So the purpose of this particular strategic initiative is to look at how we can create more trauma-informed systems to implement both prevention treatment and recover intervention as well as to reduce the incidents of trauma and its impact on the behavioral health of individuals and communities. SAMHSA's overall mission is to reduce the impact of behavioral health issues on individuals and communities within this particular initiative. We're also looking at the role of trauma and reducing its impact on our populations that we served both in behavioral health and mental health and addictions, I mean as well as those other service sectors where our populations exist or interface with and where we also partner with at the federal level including the justice system. And another purpose of this strategic initiative to better address the need of the person, with mental and substance use disorders involved with or at risk of involvement with the criminal and juvenile justice system. So we are continuing to develop strong collaborations with the Department of Justice, to work with them around collaborative projects, understanding that they play a very significant role also in addressing populations that have mental health and substance use and related issues.

Slide 7.
LARKE HUANG: I'm just going to say very quickly some of what the key goals are within the strategic initiative. We have five key areas that we're focusing on. Given the prevalence of trauma in the populations that we serve, we're looking at developing a more comprehensive public health approach to trauma. That's one of our first goal areas within this initiative.

Second area is really making screening for trauma and early intervention and treatment common practice.   It's certainly common practice in our behavioral health service sector but also looking at what other sectors our population is in entering that we might need to look how we can do screening efficiently and screening effectively to identify people early on and bring back early interventions as well. So that's all part of a public health approach.

The third piece is really reducing the impact of trauma and violence, particularly on children, youth, and families.

The fourth area is addressing the needs of people with behavioral health issues, co-occurring disorders or history of trauma in the criminal and juvenile justice system. And that today is very much what this particular webinar is focused on.
And our fifth area is reducing the impact of disasters on the behavioral health, and the trauma associated with disasters on the behavioral health of individual's families and communities.

Slide 8.
LARKE HUANG: The next couple of slides, I’m not going to go over them in detail because I really want to get you to your key presenter. But within each of our strategic initiatives, in the goal areas and objectives we have specific action items aligned with the objective. So we have an objective within this area around expanding alternative responses and diversion where people with behavioral health problems and trauma histories within the criminal and juvenile justice system. And we have a number of different activities --we have a new grant program, a new transformation technical system center, all of these things will be online in 2012. We are continuing to work with the Council of State Governments on  really bringing together sort of our different national associations and different provider groups to really how can we best meet the needs of individuals interfacing in corrections or the criminal and juvenile justice system for those people with mental health and substance use disorders. And then we have, of course, our ongoing work with the adult and juvenile drug court and our jail diversion and trauma recovery program.

Slide 9.
LARKE HUANG: Another area within this initiative is improving the ability of first responders to respond appropriately to people with mental and substance use problems and histories of trauma. Again, this is working with first time use offenders as one of our initiatives here in our prevention center. Another area of work we have going is working with the International Association of Chiefs of Police. Looking at law enforcement that often times are first responders for people in behavioral health crisis.

We also are looking to improve the availability of trauma-informed care, screening, and treatment and criminal juvenile justice systems and we support trainings and technical systems on trauma-informed care, where courts and the justice system work with the Bureau of Justice Assistance training on trauma-informed care.  So again, this is identifying the role of trauma, the centrality of trauma in the conditions that we are mandated to serve and then how we can move some of this workout into other service factors that we interfaced with.

Slide 10.
And a fourth objective is really improving the coordination of behavioral health services for persons reentering the communities from jail to prisons. We work closely with the attorney generals on the reentry council. Some of the Office of Juvenile Justice Delinquency Prevention work groups on new transitioning back to the community are beginning to think of shaping a state policy academy. We need to look at diversion issues and disproportionality for youth of color in the juvenile justice system. And then we have our Center for Application of Prevention Technologies really working with reentry coaches with a particular focus on tribal individuals reentering the community.

So, that's a very, very quick glance of our Trauma and Justice Strategic Initiative. Some of the goal areas within that and some of a few select of our action items and you can see how very much this webinar is really critically aligned with some of our work in the trauma justice initiative. So, that's it for me, Hank.

HENRY J. STEADMAN: Thank you, Larke. Dave, you're up.

Slide 11.
DAVID MORRISSETTE: Thank you, Hank. Well, Larke described one of the priorities that this webinar addresses and that's trauma and justice. The other is a priority on military families.

Slide 12.
DAVID MORRISSETTE: SAMHSA is taking an act of heart in addressing the needs of returning veterans and their families by bringing together agencies, departments, partners involved in behavioral health issues to integrate services so that military and their families have choices about who they see and what they get and that the treatment that they do get is effective. Next slide.

Slide 13.
DAVID MORRISSETTE: Some examples of these priorities, how they actually play out for SAMHSA, are things like these. The Veterans Crisis Line that many of you may be familiar with. Dial 1-800-273-TALK, punch the number one, and you get connected with particular counselors who are particularly skilled with veteran issues.
SAMHSA has also developed the technical system service now available in states and territories on the topic of military families. In response we have offered webinars to support reintegration of warriors after they return home, such as the deployment to employment and helping veterans recover and discover a working life, that was just last week.

We've also put together a package to help providers to become TRICARE certified so that military and their families have more access to, you know, providers who are insured.

SAMHSA's also coordinated policy academies with 18 states so far and we expect to do more next year. These policy academies bring together state leaders to develop strategies or plans to address one or many of the problems that face military families. These academies are developed in collaboration with many partners including Department of Defense, the National Guard, National Association of State Mental Health Program Directors, National Association of State Alcohol and Drug Abuse Directors and the National Council.

My favorite, the Jail Diversion and Trauma Recovery Program-Priority to Veterans was launched in 2008 and SAMHSA was really an early innovator in that program. Back then, there was one veteran court that we knew of in the United States and now there are something like 80 veteran courts across the country. I think with the proliferation of veteran courts and the attention that it has steadily received, it becomes a critical for us to have webinars like this for us to share information with one another, learn lessons from what we're doing and sharing that across programs whether you're SAMHSA-funded or locally grown. I think there's a lot to share with one another and our 13 states have learned a lot particularly about addressing trauma needs a veteran as well as using peers. We think that peers, where we found the peers are critical piece in the recovery of veterans who've become involved in the justice system.

One of the project directors of our grants, Jim Tackett, is a featured speaker today. I'm looking forward to hearing what he has to say. Thank you.

Slide 14.
HENRY J. STEADMAN: Thank you, Dave and Larke. And I'm going to take just a couple of minutes now to talk about some issues that I think frame the context for the behavioral health responses that we're talking about and the behavioral health needs that we are identifying. And those of you that are working with veterans have a lot of hands-on with this, maybe a little bit already known to you, but I think that it's worth at least thinking about.

Slide 15.
HENRY J. STEADMAN: And the context that I think is we're talking about is I hear people talking about what they're trying to do for the veterans, active military, military families is that the current conflicts, the OIF/OEF conflicts - Iraqi Freedom and Enduring Freedom in Iraq and Afghanistan - is that they  are different in ways that have huge implications for service needs of the people coming back from this conflict. And I want to talk very briefly about what, who is involved, where the conflict is, how that's different , what the issues are, and are different from any prior military complex as I hear people talk about them.

Slide 16.
HENRY J. STEADMAN: The “who” is the first that National Guard and Reserve make up about 40 percent of the people who have been deployed on OIF and OEF. We've never had a war in the United States before where active duty military was such a small percentage, that has huge implications, the deactivation and when people come home instead of coming back to a base having a community around them that has been anticipating in this. Instead these folks come home and after deactivation, is spread all over the geographic map where the units are and if the various different worlds that they come back into, even if it's more supportive than it may have been post-Vietnam, it's different coming back when 40 percent of the people had been called up out of regular civilian duties and have families that are scattered around in civilian locations rather than on post. Second thing that's very different is that women have never been involved in combat previously and as it stands, the Army Special Forces and Rangers developed in early 2011 what were initially called Female Engagement Teams and then ultimately I think are now called Cultural Support Teams where women have in fact been trained in combat. They're responsible for carrying the same 35 pounds of armor and supplies that every combat involved person needs and their job is in fact to work with the Afghan and Iraqi women and try and work in terms of intelligence type of work. But in the Marines, the group is called Lioness group. But to say women have never been in combat until 2011 when the Female Engagement Team, Cultural Support Team, Lioness started is really a misnomer.

Slide 17.
HENRY J. STEADMAN: One of the fundamental differences about these conflicts compared to every other conflict is there's always been a frontline of combat. You could be, say, in Vietnam or in other locations--we go back to World War II  -- where you could be in theater but you could go back on an R&R location out of combat. In today's conflict in Iraq and Afghanistan, every place is under fire. And, so that you can say women haven't been in combat but in fact they've been in the combat zone because no matter where you are, the next factor that's on the next slide is there. IEDs, Improvised Explosive Devices are everywhere and some--the highest casualties at this point are related to IEDs.

Slide 18.
HENRY J. STEADMAN: And the other thing that some of the people that work for us here, Nick who will be talking shortly has described, is the IDF, the Indirect Fire which are almost random or poorly aimed and can fall almost any place by accident or by intention that no matter where you are in this theaters, your hypervigilance is absolutely essential. And that hypervigilance when you come home gets associated with PTSD and in dysfunctional behavior, it gets people in trouble with the law in many instances. The other thing around IEDs is we've never had the level of traumatic brain injury that we've had because of IEDs and the fact that the third bullet that's on here. That medical care is so superior to what has been technology is better then in fact people survive in combat now who would not have survived. So that they have TBI, they have PTSD, these physical disabilities and so forth, but this is a different type of conflict in terms of what it produces in behavioral health needs. And finally on this slide, that that the--one of the important factors is the--to get beyond your PTSD and clinical, acute condition but in fact, sub-clinical stress reaction and normal adjustments of people coming back from these situations where every place is combat, every place is hypervigilance, every place is exposed. When they come back to civilian life, whether they're National Guard, reserve or active duty, whether they're coming back, the sub-clinical stress reactions that again can get people in trouble with the law and need to be taken into consideration to have a proper response.

Slide 19.
HENRY J. STEADMAN: The last slide is just the result of this. This study was done in the L.A. County Jail of incarcerated veterans that were there. And you can see the percentages there that have those disorders or those issues – mental disorder at 35 percent.  The jail population as a whole in the studies that have been done is around 16 percent. So that among these incarcerated veterans the rates are about twice as high as they are with the general jail population. And you can see that alcohol, drug abuse, medical conditions, homelessness, unemployment -- it's huge. Seventy three percent of the people in the L.A. County Jail who is--or identified as veterans are--were unemployed prior to their being incarcerated. And they're less likely to use VA services. In this particular study, 38 percent of incarcerated veterans that used VA services compared to 84 percent in a homeless comparison sample. So, the reality is, we've got a different war, a different conflict, extremely stressful situations and we need to do something on behavioral health needs.

And that's kind of a context, then that was all that I wanted to say and have time to say. And now, I'm going to turn it over to a person who can talk about these issues firsthand.

Slide 20.
HENRY J. STEADMAN: And this is Nick Meyer and Jim Tackett is going to follow Nick. Nick is a project assistant here at Policy Research Associates working on SAMHSA's--the SSD program here. And prior to joining PRA, just about a year ago, after he completed his Bachelor's degree in Anthropology, he was a Sergeant in the U.S. Marine Corps where he served three tours of duty in Iraq. So we've got some first person experience to talk about this and then Jim has worked on veterans affairs and issues for nearly three decades. He's based in Connecticut and he's currently Director of Veterans Services for the Connecticut Department of Mental Health and Addiction Services. In that capacity, he directs the Military Support Program, the National Guard Embedded Clinician Program, and the Jail Diversion and Trauma Recovery Services for Veterans Program that they've launched he will talk about a little bit. So with that, let me turn it over to Nick.

NICHOLAS MEYER: Good afternoon. Thank you for the introduction, Hank. As it was stated, I'm a former Marine, I served three tours of duty in Iraq. And over the next three slides, I hope to paint a picture for you of what I, veteran, fear when it comes to interactions with law enforcement. Yes, I say fear because for me as a veteran, I seen law enforcement in one of two ways on any given day. Sometimes I see law enforcement as colleagues or brothers and sisters in arms, make no mistake about it. Military law enforcement have much in common. Many of those in law enforcement are veteran service members themselves. So sometimes I see law enforcement as one of the few aspects of US society that I can relate to and they can relate to me. However, sometimes I see law enforcement as a barrier or big brother type cohort of individuals that seek to negatively affect the rights that I've earned and fought for, this is when I fear them. So as we move on, I hope to convey to you some of the reasons that I, as a veteran can see myself ending up in a criminal justice system or interactions with law enforcement. At the same time, I hope to convey to you what I expect from law enforcement as they continue to interact with veterans in the U.S.

Slide 21.
NICHOLAS MEYER: As you can see on this first slide, involvement with law enforcement and the criminal justice system can be very, very easy and unintentional for veterans and service members. And there's no easier place than that than when it comes to operating a motor vehicle. The conflicts in Iraq and Afghanistan has the--have brought about one of the most characteristic tools that insurgents and enemy combatants use. Most are improvised explosive devices. The U.S. Military has itself many, many tactics, techniques and procedures with dealing with these IEDs. One of which that I remember using quite a bit was driving towards the center of a lane on a highway. And when you're in the country for five months or more, that was tactic techniques and procedures that you use to stay alive don't relatively or easily leave you when you get back home to the States. This happened for me, I got pulled over while driving in the center of a road, even though there was a double yellow line after I came home for my second tour duty in Iraq. I did not even realize that I was driving at the center of the road until a cop pulled up behind me, turned on his light and pulled me over. He asked me why I was driving in the other side of the road, I told him, I didn't even realize it. He said, "Where are you going?"  I said, "Well, I'm on my leave, I just got back from Iraq and going to my brother's house because that's what I was doing."  Luckily for me, he did not give me a ticket or anything but he did say that, I could have killed somebody. I could have unintentionally, without even thinking of it because I was driving in the center lane, hit, head on with somebody and killed them. That struck a chord with me because I'm not home to kill anybody, I'm home to be on leave after my service and that was pretty much it. There's another way that, again, I were subject to, it came to--began as right of way incident. In Iraq, people generally get out of the way for your Humvee or your M1 Abrams tank. They don't stand in your way. There's no traffic signals as far as I can remember, stop signs. When you're on convoy and you're moving forward, the mission is the only thing that matters and nothing gets in your way.

Well, I can tell you, coming home, a Toyota Corolla is not a tank and it is not a Humvee. So people don't really get out of the way for you as much as you would like and you don't really remember that. All of a sudden, somebody pulls out in front of you, you don't expect it. Ignoring traffic signals is something I learned firsthand. I didn't even realize I was ignoring traffic signals. This happened not too long ago and I've been out of the service for five years. I was driving along and I went through a red light. And then I found myself stopping at the green light that was further down the road. Eventually, I asked my VA psychologist why I did this, he mentioned that it was a factor called disassociation. He asked me if I remember seeing any traffic lights in Iraq or stop signs, I said, no. And if I did, we didn't obey them. He said, "Well, you're blowing through lights probably because part of your brain is back in Iraq and hasn't let go of that tactic, technique or procedure that was instilled in you."  I ask him, well, then why am I stopping at a green light?  He said, "Part of your brain knows you're home and it's trying to make sense of what's going on. And it's just getting confused."  Once again, I was put in the spot where if I'm not paying attention 100 percent, even with the radio off, I could go blow a red light and kill someone or severely injure someone. And before you know it, I'm in the lap of the criminal justice system.

Slide 22.
NICHOLAS MEYER: Now, as we move on to the next slide, you will see an image of Rambo. For the past three decades, Rambo has been instilled in many of many of Americans. Why is that?  It was a very popular movie, it featured a PTSD combat veteran that comes home, can't handle his PTSD and he rained hell and destruction down upon civilians. Now, when I came home from my first tour duty in Iraq, I was driving around with some high school buddies. I got a little angry when somebody cut me off. One of my buddies said, "Don't go all Rambo on me."  I thought about this when he said it. And I realized that it really didn't make sense. Because I have these words that go on. The fact of the matter is, today's service members and veterans, even if they have behavioral health issues, they are well aware of the rules of engagement. They are trained to a standard like no other in the world in being able to distinguish between friend and foe. Weapons safety is paramount, model discipline is paramount and because of this, we have some of the best trained people in coming home stateside. So why are so many people, and why is it in the mind of so many people that when you hear somebody had PTSD, they may think of Rambo. And I think this is the paradigm shift that really needs to change as we move forward. And I think law enforcement could be the way in this. The majority of those service members and veterans that come home are very, very well trained. And they don't need to have a stigma surrounding them where some might consider them the possibility of turning into a Rambo. Now as we move on, we'll make a note that firearms are quite popular amongst veterans and service members. Even when they get out and as we move on to the next slide please, you'll realize why.

Slide 23.
NICHOLAS MEYER: In the Marine Corps alone, your riflemen, your riflemen serves above all else. We have a rifleman's creed. The rifle keeps you alive and your unit alive. Now is it a tool for survival?  Above all else when you're overseas, it doesn't leave more than an arm’s reach from you. When I served overseas, when I was in Iraq for the first time, my rifle sling during those few moments that I could get some sleep was wrapped around my leg and I slept with it. It was always there. Fast forward five months, a year later and you're home from deployment, your rifle's in the armory, you don't have anything else around you to make you feel secure, and nothing else that really keeps you alive.

This happened to me once. I was back from my first tour of duty, I was sleeping in the barracks, the Marine next to me slammed this barracks door, I heard a loud bang. I hopped out of my rack and I was looking for my rifle the entire time for about a minute. And I was panicking because I could not find my rifle. The fact of the matter is my rifle made me feel safe. I felt defenseless without it. And even when I'm out of the service, people wonder why I like to go to places like Gander Mountain. I like to go to sporting goods stores and I look at guns. And people want to know why I like to have a shot gun within reach for me when I'm sleeping. People even as close to me as my girlfriend who didn't know me when I was in the Marine Corps. It actually caused some strife among us when we first met because she thought I was obsessed with guns until I actually sat down and told her that I wasn't obsessed with guns because I was obsessed with war and conflict. I was obsessed with guns in her mind, obsessed because it made me feel safe. And I think this is the big problem with the majority of citizens out there because in this country, we're taught, police officers and law enforcement make us feel safe. And that phone with those buttons 911, that's how we feel safe in this world.

Now for service members, it's totally different. Weapons make you feel safe. I feel secure. I sleep easier when I know I have a weapon because it's what kept me alive overseas. It's what kept my unit safe overseas. And I will continue to feel like it keeps me safe back at home. And my family's safe. But this presents another problem. Because we have a certain paradigm in this country, it wasn't even too long ago, where somebody found out that I had PTSD, I had PTSD and they realized that I owned a shotgun. The first thing they said, "Is it really safe for you to have a shotgun because you have a PTSD?"  And this has been one of my greatest fears since I've gotten out. And what quite honestly kept me from going to see the proper behavioral health specialist when I got out because I was afraid that they were going to come take away my gun if I said something. Because they would assume I--because I have PTSD issues, I could turn into a Rambo or I could hurt somebody in a "flashback."  So I didn't seek care for a long time because I was so afraid of them taking away my gun. And like I said, it's so important to me. I feel defenseless without them. They've kept me alive. So as we move forward, I think that we need to realize a few things when it comes to veterans and their dealings with law enforcement and their entrance in the criminal justice system, that it can be unintentional and it could be very, very easy. We need to understand that sometimes it could be as something as simple as driving. But there are certain ways that we have driven overseas in combat that kept us alive and it's hard to let go of those when you come home very easily.

Ninety-nine percent of the service members who served and are back home and have PTSD issues, they're not going to be Rambos. They're not going to be anybody you can't trust or you have to be uneasy around. They're responsible individuals that are responsible overseas and we need to give them the benefit of doubt that they're going to be responsible back home. And finally, the gun situation; like I said, veterans shouldn't have to be afraid of losing stuff like security clearances or guns, or anything else that makes them feel like a person again. Makes them feel like being home is home because they're worried that people are going to prejudge them because of PTSD or some kind of anxiety disorder. That's all I have for now. I would like to move it on and give it back to the moderator.

HENRY J. STEADMAN: Thank you very much, Nick. And very powerful. Thank you. Jim, you want to take over?

Slide 24.
JIM TACKETT: You bet. Let's go to the next line, get that ugly mug off there.

Slide 25.
JIM TACKETT: You'll notice that I've listed the strategies that I'll be discussing this afternoon right up front. Community partnerships is perhaps the most important strategy because no one agency can do it all alone. In Connecticut, we're fortunate to have a statewide coalition that works closely on veterans issues. Our OEF/OIF task force was formed in 2005. It's comprised of representatives from numerous agencies and organizations that work cooperatively to meet the needs of returning veterans and their families. Our veteran jail diversion state advisory board was formed in December 2008. It provides leadership and the planning development and implementation of diversion and treatment services to justice-involved veterans. Regarding outreach and education, we participate in Yellow Ribbon Reintegration Program events to assure that National Guard and Reserve members and their families know about our services. We have embedded civilian coalition within guard units that have been affected by deployments. For the past five years, we have participated as faculty for Christ's intervention training for law enforcement and we do a piece on returning veterans. We also have established a robust workforce development initiative that we call the veterans resource representative training program. It's targeted to clinicians in our state system as well as community providers. The goal of the training is to demystify the VA and to encourage collaboration between our systems. We've put a lot of effort into systems integrations informing our state plan, we pulled together federal state and local providers and what came out of it was an agreement to work together, to coordinate services for justice involved veterans; particularly for newly returned veterans. This has improved veterans choice in treatment planning. And now that the VA has established its VJO program, we have some new designated go-to persons within the VA which we're excited about. A focus on systems integration has required investment in services coordination. And lastly, we recognize the importance of involving peers in all aspects of our service delivery system. I'll be referencing these strategies as I talk about two of our programs in this segment. The two programs of the Connecticut military support program and our SAMHSA supported Veterans jail diversion and trauma recovery program. Next slide please.

Slide 26.
JIM TACKETT: First step, the military support program or MSP. MSP provides statewide outpatient counseling services to reserve component service members and their families. The counseling is locally available, free, and completely confidential. The program was established through state legislations. It's funded and managed by the state of Connecticut and is available only to members and veterans of the National Guard and the Reserves and to their family members. We define families broadly. The term family includes significant others, grandparents, even neighbors; anyone who cares deeply about a veteran. MSP also provides case management and statewide transportation services. But the central feature of the program which began in 2007, by the way, is a statewide counseling operation that's accessed through a 24/7 call center. Next slide.

Slide 27.
JIM TACKETT: We currently have 425 licensed clinicians participating in our MSP panel. And together they represent a range of disciplines and clinical specialties. They serve a full range of clinical needs including marriage and family issues. Trauma, war trauma related problems, substance use disorders and child and adolescent issues. The MSP panel as well as the 24/7 call center is manned, excuse me is managed by an administrative services organization under contract with our department. When a service member or family member contacts the call center, following a brief triage assessment, they're given the names and contact information of the three clinicians in their area. An MSP community clinician follows up with them to assure that they successfully connect. The MSP program relies heavily on community partnerships and ongoing collaboration between systems. The program operates in close partnership with the Connecticut National Guard and the Reserves as well as the VA and Vet centers. Veterans and service members presenting to MSP with complex or long term care needs are routinely referred to the VA or to a local Vet center. Conversely, VA routinely refers to MSP mostly family members but often veterans as well. To touch upon the subject of confidentially for a minute--it's important to mention that because the MSP programs is administered by the Connecticut Department of Mental Heath and Addiction Services, it operates under significantly different privacy practices than the practices used by the Department of the Defense. Aside from issues of mandatory reporting, we will communicate personal health information without an individual's written consent. For this reason, MSP is an attractive treatment options for reserved component service members because they know their personal health information would be protected. Next slide.

Slide 28 .
JIM TACKETT: At the request of Major General Thaddeus Martin, the Adjutant General of the Connecticut National Guard, we began an embedded clinician program in March 2009. Today, we have 28 MSP clinicians who are embedded at the company level within units affected by deployment. The company has roughly 100 members. Imbedded clinicians are known as behavioral health advocates. They're available on site during drill weekends and then other times, by phone. They service their unit's key point of contact for behavioral health matters and they work closely with unit leaders and identifying and responding to behavioral health issues that may arise within the unit. For instance, there may be an increase in soldiers or airmen testing positives on drug tests or getting arrested. A number of guard members have been arrested on minor charges including DUI, possession, breach of peace, firearms violations as well as--excuse me--as well as intimate partner violence. Imbedded clinicians are also active in the yellow ribbon re-integration program during which they often present workshops and they work closely with their unit's family right in this group as well. Next Slide.

Slide 29.
JIM TACKETT: Shifting gears to the veteran's diversion program. In 2008, Connecticut was one of six states awarded SAMHSA funding to work on developing the statewide jail diversion program that would include trauma recovery services for veterans. Our target--our target population is our newest generation of returning veterans but we serve veterans of other periods as well. Prior to the grant's announcement, we were aware that many National Guard members who had recently returned from deployment were getting arrested on minor charges. Following the lead of the National Guard, several state agency commissioners had began working on a plan when the SAMHSA grant was announced. At the time, discussions had focused on one type of arrest, that of DUIs, the grant enabled us to broaden our approach to diversion and provided opportunity for us to think about how we can improve our ability--ability to deliver treatment and supported services to justice involved veterans. Next Slide.

Slide 30.
JIM TACKETT: Early in the grant writing process, we recognized that Connecticut has several strengths upon which we could build. We had robots interagency coordinated word nation that was ongoing as supported by the state of OEF, OYF task force. Several members of this task force formed the nucleus of our state veteran's jail diversion advisory board. We also had a well established statewide--state funded mental health jail diversion program. For the past 15 years, we've had jail diversion clinicians working in all 20 of our state courts. At the debate over the concept work and cost effectiveness of diverting individuals with mental health diagnoses had been settled long ago. We saw that our challenge would be to encourage the courts to extend the practice of diversion to veterans as well. Finally, we knew that we could rely on our statewide crisis intervention training system. They trained hundreds of law enforcement officers each year. CIT, of course, equips police officers with the knowledge and skills to interact more effectively in crisis with individuals with mood or thought disorders. During the training, we ask officers to recognize the opportunity that they have to provide leadership to a veteran who maybe struggling with trauma related problems, to help them get connected with the jail diversion programs. Next Slide.

Slide 31.
JIM TACKETT: Several years ago, SAMHSA began to urge state mental health and substance abuse authorities to actively work toward improving their ability to serve veterans and their families. They've talked a bit about this--in 2008, SAMHSA convened its first national policy academy, bringing together 10 states to begin work on state plans serving returning veterans and their families. As a recipient of the veteran's diversion grant from SAMHSA, we were required to accomplish a similar comprehensive planning process during the first year of our process--project. SAMHSA also required us to pilot the project in one region of the state before attempting to expand statewide. To assist in shaping our state plan, we brought together representatives from the Veteran's Health Administration, Veteran's Benefits Administrations, The Vet Centers and The Naval Health clinic New England, Connecticut sub-base in Groton. We recruited multiple state agencies that provide direct services to people and joining us were folks from the chief state's attorney's office, public defenders, probation officers, bail commissioners, several court based clinicians as well as state and local law enforcement. Also included were TBI service providers, interest of local non-profits, veteran service organizations and individual veterans and family members. Early on in the process, we decided that as a small state unencumbered by county lines that the central focus or overall strategy of our plan should be systems integration. Regarding strategies, again, community partnerships and peer involvement have been important to us. Over the course of our planning year which ended during the summer of 2009, all of the partners listed on this slide helped in shaping Connecticut's strategic plan. The Memorandum of Agreement that supports the plan has 29 agencies that signed off on it. And I should mention that the slide is representative of the membership composition of both our state and pilot area advisory boards. The importance of peer involvement can't be overstated. Their influence and the final blueprint that guides diversion in--in Connecticut were significant. Many veterans felt strongly that grant resources should be sued to identify and engage newly returned veterans early on before they ended up with difficult problems and if possible before they ended up with an arrest record. Next Slide.

Slide 32.
JIM TACKETT: Systems integration broadly describes Connecticut approach. And the systems that we have focused on, of course, include judicial law enforcement, VA, vet center and the state and community provider systems. We have asked each consistent with their respective missions to work together to identify, engage and refer justice involved veterans at the earliest opportunity along the criminal justice continuum. So a key feature of our approach just as prescribed by our veteran peers is early identification. Next Slide.

Slide 33.
JIM TACKETT: Depicted here is a continuum of the criminal justice system while we principally serve veterans at intercept points one through three, pre-booking arraignment and through the adjudication of their court matter, our focus is on pre-booking. We've conducted significant outreach and education among local law enforcement and court based personnel especially in the pilot area. As I'd mentioned, we actively participate in the CIT training process. I'd like to acknowledge the work that's being done by our pilot area staff; veterans diversion services in Norwich, New London, and Danielson courts are now well established. They particularly excelled in enlisting the involvement support of local police departments and have developed the systems so that veterans are identified in most cases prior to arraignment. I should have included work force development as one of our key strategies and this gets on the importance of trauma informed care. In addition to local law enforcement, our pilot area staff does an outstanding drop teaching court personnel including judges, court based clinicians, even judicial marshals about the clinical picture for many newly returning veterans. And looking at the chart, I should also mention that we try to divert veterans at intercept five who were at risk of incarceration due to probation violation. Next slide.

Slide 34.
JIM TACKETT: Because of the focus on integrating our systems, the service capabilities of many agencies located throughout the state can be contemplated during treatment planning. This means that every justice involved veteran can choose from an array of treatment and recovery support services that are provided by participating agencies from multiple systems. This approach, of course, requires strong services coordination. Informing a treatment plan that will ultimately be approved by a judge, it's not uncommon for a veteran to include services from several providers. In many cases, the treatment plan represents a partnership with VA under which some services are provided by state and local non-VA providers in the community right where the veteran lives. For instance, the veteran may elect to access primary care through a VA community-based outpatient clinic, mental healthcare from our state mental health authority or from a local non-profit and housing or drop search assistance from yet another state, VA or community provider. In this connection, systems integration supported by strong service coordination results in enhanced choice for veterans wherever they happen to live in the state. Next slide.

Slide 35.
JIM TACKETT: This slide provides a visual of the systems integration network. It captures all referrals to treatment and support services that were made for 128 veterans who were diverted. These are treatment plans that were accomplished in our pilot area. Of 348 total referrals, 33 percent involved VA, 20 percent with the State Mental Health and Substance Abuse Authority and 32 percent involve community providers. Next slide.

Slide 36.
JIM TACKETT: This slide depicts the services that veterans were referred to. You can see 63 percent involved substance abuse, 53 percent mental health issues, 27 percent recollected employment needs and nearly one in five were either homeless or at risk of becoming homeless. When we look at all referrals that were made to the--in the 128 treatment plans, we come up with the mean of 2.7 referrals. So many veterans treatment plans reflect multiple referrals. Next slide.

Slide 37.
JIM TACKETT: Our plan going forward, chief among our goals going forward is to sustain the work of the SAMHSA and the pilot area. Secondly, we're working to expand the project statewide by stepping into the footprint of the existing statewide mental health jail diversion program. This is being accomplished through workforce development. A little less than half of our mental health jail diversion clinicians around the state have already been through the Veterans resource representative training program. That's our comprehensive workforce development process that works to demystify the VA and equip clinicians with knowledge and ability to serve veterans not only in treatment planning but also in coordinating services with the VA. We'll also be establishing a statewide mentor program. The goal is to train 20 to 30 mentors who will be available to report to an area jail to engage a veteran who's just been arrested. Mentors will be alongside veterans in court through the completion of the adjudication process and will also help them connect with their treatment plan and we've begun planning on this--at this pro--this particular program and we'll be looking to implement the program next summer.

Slide 38.
JIM TACKETT: That would conclude my comments. I want to make sure we have enough opportunity for discussion.

HENRY J. STEADMAN: Well, I thank all of the speakers because we have gotten to the Q&A portion of this exactly at the minute we wanted to.

Slide 39.
HENRY J. STEADMAN: We have 20 minutes left if there--if there are 20 minutes worth of questions. And I will do the monitoring of the questions that people have been typing in and have referred them to the person that I think might best answer them, but other people on the panel are welcome to chip in.

The first question is I think goes to you Jim, it was from a person who wanted to know how your confidentiality that you mentioned earlier is guaranteed and related why is that so important in terms of what are the risk of disclosing trauma, related mental health issues and, you know, what are the benefits of disclosing. So, I think if they're all nested as one set of questions. What are the costs?  What are the benefits and how do you assure the confidentiality?

JIM TACKETT: Well, the difference is between private practices, between those in the practices employed by DoD and by others not DoD that have to do with the release of personal health information. A clinician within their system will release information directly to frontline leadership within a National Guard unit, for instance. And even TRICARE, the DoD can have access to personal health information through TRICARE. Stigma is huge still. There's been a lot of study into this, a lot of research, Charles Hoge, he did a paper and that was published by the New England Journal of Medicine in 2004 and in there, he depicted stigma as a many-headed hydra. Well over 50 percent of army veterans that were surveyed indicated that they were reluctant to step forward and access services if they recognized that they had some behavioral health problems because their leadership would define them differently, their fellow soldiers would define them differently and they would view themselves as weak. That research has been underlined since then by a survey that was done by Harris International in 2008. They found similar high numbers, 60 percent who worried. And the mental health task force, the DoD's task force in 2007, underscores stigma as being a big problem as well.

So, the privacy practice that we offer protects personal health information and soldiers choose to come to us for the military support program because they know that their business won't be on the street, that it won't get back to their frontline leader, that their status within the guard will not be placed at risk. Now, there are times when we work intensively with a service member who we consider to be at risk, who may have orders for deployment, for instance. And if it's our judgment that it's not safe for that soldier to be deployed. We work intensively with that soldier to encourage that the soldier communicate his current health condition to his frontline leaders and we secure consent and in every instance, we've been able to do this to get written consent so that we can talk with the behavioral health folks within the military. So it's a partnership with individual soldier in handling that personal health information in that instance.

HENRY J. STEADMAN: Jim, let's maybe move on to another question. A number of questions have come in different forms about, "Can you access the PowerPoint slide?"  And the answer is, "Yes, you will be able to."  As I said at the outset of the call, everyone that has been registered for this webinar will get a link. The link is also on a slide that we'll show in a little bit. And that link to the co-occurring disorders website will have the whole audio and the video and the PowerPoint to download. So, yes, the slides will become available. It may take a day or so to get that up but it will get up. Jim, there's a quick factual question. One of the questions--I think I know the answer but I'll defer to you is, MSP exists only in the state of Connecticut?"

JIM TACKETT: You know, I've heard of other similar programs around the country. I think out in Minnesota which is the birth place of Colonel John Morris, the architect of the Yellow Ribbon Reintegration Program. I think that they are now providing outpatient counseling statewide and I know that in California, TRICARE West for a period of time was also providing outpatient counseling around the state. There must be, by now, similar programs available for reserve component service personnel and their families but I'm not aware of it.

HENRY J. STEADMAN: Okay. Thank you. A number of the questions that people are--they're very poignant questions and rather involve, let me read this one and see what you thought of it. It's a very complex question. We have specialists. I often screen many veterans who have received various forms of assistance; housing, medical, financial, et cetera and there seems to be nothing in place to assist them with child support issues and in light of that, although a veteran may receive a housing voucher which requires 30 percent of their income, when child support kicks in, they are no longer able to maintain housing or pay essential bills. It's not really a question but an observation and I guess, do you have any reaction to that, Jim, in terms of how your program could try to respond to those complex issues.

JIM TACKETT: Again, this is the partnerships within our taskforce. We just do the best we can, trying to come together with a plan to address those issues. You know, I think about the strategies that have been embraced by the discussion coming out of the White House, Michelle Obama and Jill Biden, one of the prominent strategies in their plan is to address this issue. So it's recognized among active duty, military families and it's certainly a case the listener describes in working with folks that are looking for work. It's a challenge and I'm hoping that out of the work of the White House that we may see some significant resources in this area.

HENRY J. STEADMAN: There's one question that was directed at SAMHSA if Larke or David is still on the call and I'm not sure but let me read the question that was stated. What is SAMHSA doing to encourage the VA to implement a domestic violence program that is certified with the state to assist veterans. Is there anything going on in SAMHSA that would relate to that type of questioning, Larke or David?

DAVID MORRISSETTE: This is Dave. I'm not aware of any activity in that, are you Larke?

LARKE HUANG: Actually, no, I'm not. I mean, I think we do some work with the VA. We do some work with the Domestic Violence Network but we haven't really connected that up. It's a good question.

JIM TACKETT: Hi. This is Jim. In Connecticut, we've recognized such a high number of newly returning veterans involved in intimate partner violence, family violence and we reached out to family, to clinicians in our family court down in the pilot area. We're in the process now of putting together a work group to address the issues so that we can come up with some effective ways. So that's an issue that's recognized here and we're trying to pull together to address it. On the work groups are some folks from our state's Domestic Violence Coalitions as well as court based clinicians.

LARKE HUANG: This is Larke again. Jim made me think of it--in another program on our child network program, we do have some grantees that are focused on trauma and families with returning military and family violence issues.

HENRY J. STEADMAN: Okay. Another question that was asked a couple of times had to do with Military Sexual Trauma, MST is the acronym. The question was “where does it fit?”  I think that it goes back to maybe my presentation as something that is different about this conflict as more women are involved. There is more awareness, a specific designation, screening, and receptivity to being responsive to Military Sexual Trauma. The presentations that I’ve heard on the issue are that one has to be careful that it's not just a women's issue but males also are victims of Military Sexual Trauma. It's a relatively significant behavioral health issue. I'm not sure, Jim, if this is anything in Connecticut or any other programs you’re aware of that specifically relate to that. I think there clearly is an awareness that didn't exist and an attempt to be responsive to that.

JIM TACKETT: You bet. And you know, the vet center system is playing a lead role in this area. They have designated clinicians within every vet center. We work closely with them as well as with the VA healthcare system, the medical centers. They too have individuals with expertise in this area. As well within our military support program recognized that we got some go-to folks in our clinical panel that we often refer to but it is a huge problem. In the women's clinic at the VA in West Haven, I can remember asking the clinician how many women are presenting a history of MST and the answer was all of them. So, it's certainly a new phenomenon that we need to deal with.

HENRY J. STEADMAN: One question is a factual one that I can quickly answer. The question was if there was a citation for the L.A. County Jail study that I used in my presentation and here is the citation for those who want it. It's from Psychiatric Services, it's the journal. It's volume 54 in 2003, pages 201-207 and Jim McGuire is the lead author and it's called "Health Status, Service Use and Costs Among the Veterans Receiving Outreach Services in Jail or Community."

Actually there are a couple of questions that have come in around the interphase or county mental health. One was that the VA had a partnership with helping mental health or other mental health services funded by the county. What challenges can one expect to have when you start working with counties on veterans issues. Now Jim, do you want to take a crack at that?

JIM TACKETT: I'm sorry I had the mic off. I followed the articles, you know, some emerging new programs through several newsgroups and I've read about the VA going in this direction to contract directly, particularly in rural areas. I know that the VA, two years ago launched a pilot project where they sought to identify federal health clinics in state run operations in rural areas within three VISNs and there was some significant funding that was provided there. There is a keen interest within the VA right now of doing a better job of working with folks in rural areas and I think most of the focus is around contracting with community providers/local mental health clinics that can address that need.

HENRY J. STEADMAN: One of the areas that Nick talked a lot about in his presentation was the role of law enforcement and how critical they are. This isn't a question, but just an observation and I think that this is something, in addition for the person that submitted this about Cook County in Illinois. It's something that's going on nationally in a lot of programs. What the person asked was whether that we would mention that civilian police training on veterans issues has become integrated as a core component of the crisis intervention team training and some of the training are of VA police on these issues. And also the inclusion in correction officer training in jails. There's actually a national CIT conference in two weeks in Virginia Beach and I think that when you go to those conferences, you see there's a huge increase in the awareness of how important veterans issues are in terms of police response to veterans.

But also again as Nick mentioned, many first responders -- law enforcement and other first responders -- are also veterans themselves and have been exposed to the trauma that we have been discussing and have some of the sequelae to those trauma. But the CIT training is something, in the observation that was submitted, that Chicago/Cook County is paying attention to but I think it is something that we're seeing growing in a lot of other parts of the country.

Let me read a relatively challenging question that I've heard from others and Jim, maybe you can take a crack at it and maybe I'll just give some response. It says “one of our biggest problems in our state's largest jail is that the Veterans Administration has a hands-off policy once the person is booked into the jail here. It's frustrating trying to get services and evaluations done for those folks because we're told that they can't help us as long as our guy is in jail.”  And again, I think that has to do with the coordination and integration issues that you're talking about, but also had some regulations that's related to the Veterans Administration on what they can legally do. How has that shown up in Connecticut?  Are you seeing that in other people and other states that you're talking to, Jim?

JIM TACKETT: Well, it's true that for many, many years that was the policy that once a person was incarcerated, that not only was their service connected disability compensation reduced to 10 percent, the VA couldn't serve them. A new day has dawned. The new Veterans Justice Outreach program authorizes VA to go into the jails and that was the new VJO program. It was an earlier program, a reentry program in place and it's been in placed for several years which authorized the VA to go into prisons as part of the reentry process to begin developing a plan -- a plan for housing, a plan for work, a plan reconnecting with the VA. So the VJO program is new. In Connecticut, the Veterans Justice Outreach, we have two clinicians. One of them has been authorized to go into the jail, another one is going through the screening process from the Department of Correction. And they are going to be able to go in to assess veterans needs and communicate the VA's ability to address those needs to the system and to the courts.

HENRY J. STEADMAN: There's one question that we can answer quickly because, unfortunately, the answer is no, I think. “What screening tools are currently used to assess traumas specifically with veterans?”  Great question and I would admit that we actually have a grant proposal into a funding agency to in fact establish that very thing. But to my knowledge there is no trauma screening instrument that's been specifically geared to veterans. And I think it's a really important issue, but my little portion of this presentation was to say this is different. I think that the trauma forms that have been developed in terms of lifetime history - the physical and sexual abuse - that are very important and  good screening instruments, but as it relates to combat stress or sub-clinical trauma  I think that we need something that is in fact targeted specifically to those situations and those manifestations. But the answer is no to the question.

Another fairly specific question, it says “does it make sense to have a veteran's track in an existing co-occurring disorders court?”  The answer is there could be and there's no answer to that. I think that what you see in the veteran's treatment courts that Dave Morrissette referred to earlier, where there's approximately 80 or so nationally, is that there's no standard model that communities are doing it a lot of different ways. It's a matter of how can you effectively identify veterans so as to give them tailored services. And peers that will be effective for veterans is different than the usual peer support services that are available when they are certified or available in your state. If in fact in your community, if that would be the most efficient and effective way to do that, and you had a judge who wanted to, which I think is a big issue, it could work. But there's no necessary reason it wouldn't work and there's no necessary reason it would work. It would depend very much on the local situation and the people involved. And I think our next we are going to run out of time.

Slide 40.
HENRY J. STEADMAN: Let us put up the last slide that has the information that I keep referring to everyone to which is the link that in a day or so you'll be able to get the audio and the video and the PowerPoint at that location. And we'll also be sending a contact out that we would ask you to take a few minutes and fill out the evaluations so that the stuff that you like that we did and the stuff that you didn't like that we did that we can hear about and that we can do a better job the next time we do it. I thank the presenters, the SAMHSA staff, Larke and David, and Jim and Nick. It was really a great set of ideas and great challenges and these are really, really important issues which indicate why there are so many people on the call today. And all of you that are out there to work in highlighting these issues, no  matter where you are in the systems, we really, really do appreciate that you work that you're doing. Let’s all try and do a better job for the people that really need the help, the veterans, the no-active duty military in the families. And we thank you very much and good luck.