Despite the success of several US Department of Veterans Affairs (VA) initiatives in facilitating psychosocial functioning, rehabilitation, and re-entry among veterans experiencing homelessness and/or interactions with the criminal justice system (ie, justice-involved veterans), suicide risk among these veterans remains a significant public health concern. Rates of suicide among veterans experiencing homelessness are more than double that of veterans with no history of homelessness.1 Similarly, justice-involved veterans experience myriad mental health concerns, including elevated rates of psychiatric symptoms, suicidal thoughts, and self-directed violence relative to those with no history of criminal justice involvement.2
In addition, a bidirectional relationship between criminal justice involvement and homelessness, often called the “institutional circuit,” is well established. Criminal justice involvement can directly result in difficulty finding housing.3 For example, veterans may have their lease agreement denied based solely on their history of criminogenic behavior. Moreover, criminal justice involvement can indirectly impact a veteran’s ability to maintain housing. Indeed, justice-involved veterans can experience difficulty attaining and sustaining employment, which in turn can result in financial difficulties, including inability to afford rental or mortgage payments.
Similarly, those at risk for or experiencing housing instability may resort to criminogenic behavior to survive in the context of limited psychosocial resources.4-6 For instance, a veteran experiencing homelessness may seek refuge from inclement weather in a heated apartment stairwell and subsequently be charged with trespassing. Similarly, these veterans also may resort to theft to eat or pay bills. To this end, homelessness and justice involvement are likely a deleterious cycle that is difficult for the veteran to escape.
Unfortunately, the concurrent impact of housing insecurity and criminal justice involvement often serves to further exacerbate mental health sequelae, including suicide risk (Figure).7 In addition to precipitating frustration and helplessness among veterans who are navigating these stressors, these social determinants of health can engender a perception that the veteran is a burden to those in their support system. For example, these veterans may depend on friends or family to procure housing or transportation assistance for a job, medical appointments, and court hearings.
Furthermore, homelessness and justice involvement can impact veterans’ interpersonal relationships. For instance, veterans with a history of criminal justice involvement may feel stigmatized and ostracized from their social support system. Justice-involved veterans sometimes endorse being labeled an offender, which can result in perceptions that one is poorly perceived by others and generally seen as a bad person.8 In addition, the conditions of a justice-involved veteran’s probation or parole may further exacerbate social relationships. For example, veterans with histories of engaging in intimate partner violence may lose visitation rights with their children, further reinforcing negative views of self and impacting the veterans’ family network.
As such, these homeless and justice-involved veterans may lack a meaningful social support system when navigating psychosocial stressors. Because hopelessness, burdensomeness, and perceptions that one lacks a social support network are potential drivers of suicidal self-directed violence among these populations, facilitating access to and engagement in health (eg, psychotherapy, medication management) and social (eg, case management, transitional housing) services is necessary to enhance veteran suicide prevention efforts.9
Several VA homeless and justice-related programs have been developed to meet the needs of these veterans (Table). Such programs offer direct access to health and social services capable of addressing mental health symptoms and suicide risk. Moreover, these programs support veterans at various intercepts, or points at which there is an opportunity to identify those at elevated risk and provide access to evidence-based care. For instance, VA homeless programs exist tailored toward those currently, or at risk for, experiencing homelessness. Additionally, VA justice-related programs can target intercepts prior to jail or prison, such as working with crisis intervention teams or diversion courts as well as intercepts following release, such as providing services to facilitate postincarceration reentry. Even VA programs that do not directly administer mental health intervention (eg, Grant and Per Diem, Veterans Justice Outreach) serve as critical points of contact that can connect these veterans to evidence-based suicide prevention treatments (eg, Cognitive Behavioral Therapy for Suicide Prevention; pharmacotherapy) in the VA or the community.
Within these programs, several suicide prevention efforts also are currently underway. In particular, the VA has mandated routine screening for suicide risk. This includes screening for the presence of elevations in acute risk (eg, suicidal intent, recent suicide attempt) and, within the context of acute risk, conducting a comprehensive risk evaluation that captures veterans’ risk and protective factors as well as access to lethal means. These clinical data are used to determine the veteran’s severity of acute and chronic risk and match them to an appropriate intervention.
