Women are the fastest growing segment of the criminal justice population. Arrests among women increased by approximately 1.5% from 2005 to 2009 (compared to a decrease in arrests of men by about 5% during the same period; U.S. Department of Justice and Federal Bureau of Investigation 2009). Similarly, from 2000 to 2006 the average annual rate of growth for female prisoners in U.S. prisons and jails has outpaced that for males: an almost 3.5% increase for women compared to 2% increase for men (U.S. Department of Justice and Justice Statistics 2008). The majority of women are sanctioned in the community, with over 800,000 women on probation or parole (Glaze & Bonczar, 2011).

The increasing involvement of women in the criminal justice system has serious implications for health and well-being within the U.S. Between 60% and 80% of female prisoners have children, with about 70% of incarcerated mothers having children under the age of 18 years (Pollock 2002). Women’s involvement in the criminal justice system separates families and is more disruptive than paternal incarceration, because unlike their male counterparts, women are the primary caretakers of their minor children prior to incarceration (Mumola, 2000). Maternal incarceration is associated with a host of negative psychological, educational, and social sequelae for children—including involvement in the child welfare system (Child Welfare League of America, 2001; Greene, Haney, & Hurtado, 2000; Katz, 1998; Poehlman, 2005; Seymour, 1998; Trice & Brewster, 2004). Approximately 8–10% of the children of female prisoners are in some form of out-of-home care (Seymour, 1998), with the most common arrangement for the child being the grandparent (Johnson & Waldfogel, 2002). One in ten children of incarcerated mothers will be incarcerated themselves by the time they reach adulthood (Johnston, 1995 cited in Katz, 1998).

Incarceration also places women in close proximity to populations of women with high rates of infectious diseases (Freudenberg, 2002; Moore & Elkavich, 2008). HIV/AIDS, tuberculosis (TB), and hepatitis rates are particularly high among inmates and disproportionately affect women (Centers for Disease Control and Prevention 2004). For example, a greater percentage of female inmates are HIV positive compared to their male counterparts: 2.6 % of females vs. 1.8% of males (Maruschak, 2005, 2006). In some states, up to 15% of the female prison population is HIV positive (Maruschak, 2005, 2006). Similarly, rates of TB and hepatitis C among incarcerated populations are between 9 and 13 times higher than the general population, with both diseases occurring more frequently among incarcerated women than men (Levin, Bick, & Stubblefield, 2002; National Commission on Correctional Health Care, 2002; Nijhawan, Salloway, Nunn, Poshkus, & Clarke, 2010; Young, 2000). In addition, women with felony convictions may be negatively impacted by criminal justice involvement, including: limited employment opportunities; exclusion from public housing and welfare benefits; restricted access to financial support for higher education; and disenfranchisement (Allard, 2002; Iguchi, Bell, Ramchand, & Fain, 2005).

Finally, with the exception of probation, women of color constitute the largest proportion of women in the U.S. criminal justice system; approximately 67% of incarcerated women are women of color (Glaze & Bonczar, 2011; Greenfeld & Snell, 1999). In 2005, black women were more than 3 times as likely as white women to be incarcerated in prison or jail, and Hispanic women 69% more likely (The Sentencing Project, 2007). Moreover, the majority of women in the criminal justice system are poor. Prior to arrest, 60% of incarcerated women were not employed full-time, 37% had incomes under $600, 30% were receiving welfare benefits, and 44% had not completed high school (Greenfeld & Snell, 1999). The confluence of race and class among women in the U.S. criminal justice system disproportionately affects the health and well-being of women of color, particularly poor women of color. Accordingly, the increased involvement of women in the criminal justice system has perpetuated racial disparities and biases in the areas of child well-being and the child welfare system, infectious diseases and other markers of public health, and additional domains of functioning such as employment, educational attainment, and voting rights.

Despite the rapid increase of women in the criminal justice system and the serious repercussions associated with its growth, national debates on crime and justice, as well as the majority of research on criminal justice populations, have typically focused on men. Current approaches to women in the criminal justice system are largely adapted from those designed for men. These practices do not properly acknowledge that women and men differ with regard to: (a) initial risk factors for criminal justice involvement; (b) the ideal content and delivery of programs while incarcerated or under supervision; and (c) the unique challenges women face with regard to community reintegration (Bloom, Owen, & Covington, 2003). Consequently, women in the criminal justice system represent a critically understudied population. Programming and interventions that reduce women’s involvement in the criminal justice system and ameliorate the negative consequences associated with criminal justice involvement are urgently needed. However, the development of such programming and interventions represent only half of equation. Equally important is the identification of factors that might promote the recruitment and retention of women in such programs.

Therefore, the overall aim of this paper is to provide a comprehensive framework for developing evidence-based, gender-specific intervention strategies that prevent criminal justice involvement and reduce the associated negative consequences among women in the criminal justice system. To this end, the paper is divided into three subsections. Section one provides a conceptually-guided review of the psychological needs and challenges of this population. This review synthesizes the extant research on women in the criminal justice system and provides direction for assessment and intervention strategies. Section two presents findings from focus groups conducted with women sanctioned in the community (i.e. on probation or parole). The primary goal of the focus groups were to better understand the challenges of engaging and retaining criminal justice-involved women in community-based psychosocial interventions. In the third and final section of the paper, implications and recommendations are presented.

Conceptual Review of Psychological Needs and Challenges

Research investigating women in the criminal justice system has generated a plethora of descriptive findings and recommendations for treatment interventions without the benefit of conceptual guidance. Therefore, a framework that provides a conceptual synthesis of the available psychological research is a necessary prerequisite for the development of effective assessment and intervention strategies for this population. Examination of the literature indicates that three primary factors appear to both facilitate and complicate women’s involvement in the criminal justice: victimization; mental disorders; and substance use.

Overlapping Relationships: Victimization, Mental Disorders, and Substance Use

The significant and overlapping relationship between victimization, mental disorders, and substance use is well established (Bradley & Follingstad, 2003; Green, Miranda, Daroowalla, & Siddique, 2005; Jordan, Federman, Burns, Schlenger, Fairbank & Caddell, 2002; Logan, Walker, Jordan, & Leukefeld, 2006). Research supports a number of competing explanations for the relationship among these factors: 1) women’s experience of victimization may lead to mental health problems (e.g. PTSD; depression) that in turn are regulated through the use of drugs; 2) the combination of mental health problems and substance use leads to victimization; and 3) substance use may facilitate mental health problems by placing drug-involved women at risk for victimization (Logan et al., 2006). Researchers and practitioners alike have concluded that for many women the relationship between and among these factors is reciprocal. In the following section, the available research on each factor as it relates to women in the criminal justice system is discussed.

Victimization

The experience of victimization has been identified as one of the most significant factors contributing to women’s involvement in the criminal justice system (Bloom, Owen, & Covington, 2003). Lifetime rates of prior victimization among incarcerated women have been found to range from 44% to 80% (Browne, Miller, & Maguin, 1999; Greenfeld & Snell, 1999; McClellan, Farabee, & Crouch, 1997; Owen & Bloom, 1995; Tusher & Cook, 2010; Walsh, Gonsalves, Scalora, King, & Hardyman, 2011). For many women involved in the criminal justice system, victimization is first experienced during childhood. Physical abuse, sexual abuse, and severe neglect during childhood are associated with both juvenile delinquency and adult criminality (as measured by arrests; Widom, 1995; Widom & Ames, 1994). Childhood abuse and neglect increases the likelihood of arrest as a juvenile by 59%, as an adult by 28%, and for a violent crime by 30%, regardless of gender (Widom & Ames, 1994). One study reported that women who were abused or neglected in childhood were 73% more likely than a comparison group of women to be arrested for property, alcohol, drug, violent, and misdemeanor offenses such as disorderly conduct, curfew violations or loitering (Widom & Ames, 1994). Additionally, women who were abused and neglected as children were also more likely to suffer from other mental health disorders, particularly PTSD, depression, and dysthimia (Horwitz, Widom, McLaughlin, & White, 2001; Messman-Moore & Long, 2003).

Mental Disorders

The psychological consequence most closely associated with victimization is post-traumatic stress disorder (PTSD). Given the prevalence of victimization among women in the criminal justice system, it is of little surprise that these women are also disproportionately affected by PTSD (Jordan et al., 2002; Jordan, Schlenger, Fairbank, & Caddell 1996; Teplin, Abram, & McClelland, 1996). One study found that 78% of women incarcerated in prison had experienced at least one event that met DSM-III-R criteria for an extreme event (Jordan et al., 1996). Similarly, 30% had experienced a traumatic event and six or more PTSD symptoms in the past six months (Jordan et al., 1996). Among female jail detainees, approximately 34% met the criteria for a lifetime diagnosis of PTSD and 22% met the criteria for PTSD within the past six months (Teplin et al., 1996). These prevalence rates are considerably higher than those found in the general population, where the lifetime prevalence of PTSD is 10.4% (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995).

Furthermore, women who experience stressful events, including victimization, have a greater likelihood of subsequently developing depression than their male counterparts (Maciejewski, Prigerson, & Mazure, 2001). In fact, major depression is the third most common psychiatric disorder among women in the criminal justice system (after PTSD and substance abuse/dependence); lifetime prevalence is estimated to be between 13% and 16% for incarcerated women (Jordan et al., 1996; Teplin et al., 1996). Although the co-occurrence of depression and victimization among women in the criminal justice system has been minimally examined, estimates of the relationship between these two factors can be found in non-criminal justice populations. For example, depression among women who experience intimate partner violence (IPV) range from 39 to 69% (Logan et al., 2006) and are as high as 75% among women who have been raped (Faravelli, Giugni, Salvatori, & Ricca, 2004). Moreover, compared to men, women with depression are more likely to suffer functional impairments (including difficulty maintaining work, household, or schooling functions) (Foley, Neale, Gardner, Pickles, & Kendler, 2003). These findings strongly suggest that victimization and subsequent depression have a gendered effect on functional impairment and quality of life among women.

Finally, the co-occurrence of PTSD and depression is also often noted among women with victimization histories. Specific estimates are not available for women in the criminal justice system, though data from the National Comorbidity Survey indicate that women are twice as likely as men to have co-occurring depression and PTSD (Kessler et al., 1995). In fact, among samples of women who have been victimized (e.g., rape, IPV), major depressive disorder rarely occurs in the absence of PTSD (Cougle, Resnick, & Kilpatrick, 2009; Resick, 2001; 2004).

Substance Use

Substance abuse and dependence are the most common psychiatric disorders among women in the criminal justice system. More than 70% of female jail detainees report a substance use disorder, with 32.3% meeting the criteria for alcohol abuse/dependence and 63.6% meeting the criteria for drug abuse/dependence (Jordan et al., 1996; Teplin et al., 1996). In fact, compared to women in the general population, female jail detainees are nearly 9 times as likely to suffer from substance abuse or dependence (Jordan et al., 1996; Teplin et al., 1996).

Not only are substance abuse/dependence the most common psychiatric disorders among this population, the legal penalties associated with substance use have contributed to the surging number of women in the criminal justice system. Nearly 1 in 3 women serving time in state prisons report committing the offense to obtain money to support a drug habit (Bloom, Owen, & Covington, 2003). Furthermore, drug offenses constitute 29.1% of the most serious crimes for which women were incarcerated in prison (Harrison & Beck, 2006) and 29.2% of crimes for which women were incarcerated in jail (James, 2004). Among convicted female jail inmates, 34.4% reported using drugs at the time of offense and 46.3% reported using both drugs and alcohol; nearly half described themselves as daily users (James, 2004). Women in the criminal justice system also use drugs more often in the month prior to incarceration than their male counterparts (Greenfeld & Snell, 1999), and a higher percentage of female inmates reported using drugs at the time of offense compared to male jail inmates (James, 2004).

Available research strongly suggests that the relationship between childhood abuse and neglect, and adult criminal justice involvement is at least partially mediated by adult substance use and/or the presence of other mental health disorders (Golder, 2005; Horwitz et al., 2001; Schuck & Widom, 2001; Vaddiparti et al., 2006). As evidence, women who have experienced childhood victimization are more likely to use illicit drugs (Wilsnack, Vogeltanz, Klassen, & Harris, 1997) and alcohol as adults than their never abused peers (Horwitz et al., 2001; Wilsnack et al., 1997).

Women in the criminal justice system are also over-represented at the intersection of substance use and other mental disorders. Nearly half of women probationers identified as mentally ill were using alcohol and/or drugs at the time of their offense (Ditton, 1999). Among female jail detainees with serious mental illnesses such as schizophrenia or major affective disorder, 72% have a comorbid alcohol or drug use disorder (Teplin et al., 1996). This rate is significantly higher than adults in the general population, where only 12.2 % suffered from both a serious mental illness and a substance use disorder (Epstein, Barker, Vorburger, & Murtha, 2004).

What Does It Mean?

The majority of women in the criminal justice system have been victimized at least once in their lives. For many of these women there is a long history of victimization beginning in early childhood and continuing into their adult years. Regardless of the temporal ordering of victimization, mental disorder, or substance use, the cumulative risk for women in this population is greatly magnified. Independently and in concert, these factors increase the likelihood of women’s exposure to dangerous situations and activities, negatively impact their health and well-being, and increase their probability of criminal justice involvement.

Given these issues, programming and interventions that selectively target single behavioral risk factors are likely to be ineffective. Emerging research demonstrates that the complicated issues presented by this population are best met through integrated intervention models that address the most salient issues facing this population—victimization, mental disorders, and substance use (Cocozza et al., 2005; Logan et al., 2006). Specifically, findings from the Women, Co-occuring Disorders, and Violence Study (WCDVS) demonstrated that interventions providing highly integrated treatment of victimization, substance use, and other mental disorders exhibited a greater effect on drug use severity and mental health outcomes than interventions with less integration (see McHugo et al., 2005 for a detailed description of the WCDVS research methods; Clark & Power, 2005; Cocozza et al., 2005; Morrissey et al., 2005). Moreover, women with more severe problems received a greater benefit from integrated services than those with less severe problems (Morrissey et al., 2005). Finally, the total cost of service use was no higher for integrated treatment than at comparison sites, and integrated interventions were associated with significantly lower jail cost (i.e. less women were incarcerated as a result of participating in the integrated intervention than treatment as usual; Clark & Power, 2005; Domino, Morrissey, Nadlicki-Patterson, & Chung, 2005).

Evidence for comprehensive and integrated intervention models is building; however, even the most effective programs are of little help if women cannot be engaged and retained in the treatment. Once out of prison or jail, women with criminal justice involvement, particularly drug-involved women, are a notoriously hard to reach population. In order for program planning and intervention strategies to be the most effective and efficient, a full understanding of the complexities of women’s lives both within the institution and in the community must be incorporated.

Focus Groups

The following section presents findings from focus groups that sought to identify factors that promote or impede the engagement of criminal justice-involved women in psychosocial interventions. Focus groups were conducted with women being sanctioned in the community (i.e. on probation or parole) rather than incarcerated women for two reasons: 1) women being sanctioned in the community represent the majority of women in the criminal justice system; and 2) concerns regarding engagement and retention are greatest when women reside in the community.

Methods

Four focus groups were conducted in 2004 and 2005 with adult women who had been remanded to probation or parole (N = 40). A convenience sample of participants was recruited from four community-based organizations in a Midwestern metropolitan area. Two of the participating agencies were homeless shelters that provide free temporary housing, recovery-based services, and/or detoxification programs to both men and women. The other two participating organizations were not-for-profit agencies that provide professional drug treatment and rehabilitation services to drug-involved individuals. One of the drug treatment agencies was an intensive outpatient program, and the other a long-term residential recovery program.

Eligibility criteria for the study were that women be at least 18 years of age; currently sentenced to probation or parole or had been sentenced to probation or parole within the past year; have the ability to converse in English; and reported using one or more illicit drugs within six months immediately prior to enrollment in probation or parole.,Footnote 1, Footnote 2 Following the screening procedures, eligible participants were individually administered an approved institutional review board consent form to sign. Participants were compensated $10.00 for participation in the focus groups. The informed consent and study protocols were approved by the University of Louisville Institutional Review Board, and the study was granted a Certificate of Confidentiality by the National Institute on Drug Abuse.

Focus Group Protocol

Focus groups lasted approximately 90 minutes to 2 hours and were comprised of 5 to 12 women meeting the aforementioned eligibility criteria. Each of the four focus groups was facilitated by the second author, and two of the focus groups were co-facilitated by trained masters-level social workers who were also female. The primary aim of the focus groups were to obtain crucial information needed to elicit and explore ways in which contextual factors may affect participation in psychosocial interventions among women being sanctioned in the community. A structured interview guide was used for each focus group and included questions assessing service needs, barriers to service utilization, and experiences in the criminal justice system.

Analysis

Focus groups were audiotaped and transcribed verbatim. Content analysis was used to inductively analyze the transcriptions; analysis generally followed the grounded theory approach described by Strauss (1987). Transcripts from the focus group sessions were reviewed first in order to develop a list of broad themes and concepts emerging from the data. Further reduction of data and coding occurred after the development of a preliminary set of analytic coding categories on the basis of conceptual relevance. Transcripts were then reviewed for select chunks of text in which relevant data were contained (Strauss, 1987). Three coders (the latter three authors of the paper) reviewed all transcripts. During each stage of the analysis, findings were reviewed and discrepancies were discussed until consensus was reached.

Results

Analyses of the focus group transcripts identified four overarching themes: the benefits of the criminal justice system; barriers to employment; the need for safe, affordable housing; and the pervasive influence of substance use. Each of these areas will be discussed in the following section. Textual support, taken from the transcripts, is presented in the form of quotes from the women to illustrate each of four themes.

Benefits of the Criminal Justice System

With regard to the criminal justice system, many women expressed satisfaction or happiness about being arrested because it facilitated their entry into drug treatment. However, the women did not feel it should be necessary to “catch a charge” and/or serve a jail term in order to receive treatment.

…I don’t think prison is going to help me. You sending me to prison every time I get dirty [test positive for drugs] is not going to help me. I don’t understand why the system sends you to prison every time you get a dirty. Prison is not going to help my disease…you get around a lot of other people that’s got these other issues and then there you are.

Unfortunately, in 2005, less than 1% of all women needing drug or alcohol treatment actually received the treatment they needed (Substance Abuse and Mental Health Services Administration [SAMHSA], 2005). Similarly, treatment is not routinely available for the majority of women in the criminal justice system (Lurigio, 2000). The need for drug and alcohol treatment is particularly salient given that research indicates that targeting substance abuse is a highly effective strategy for reducing recidivism (see Golder et al., 2005 for a review of these issues). Echoing the words of the woman above, there is a clear and pressing need for drug- and crime-involved women to find entry into treatment outside of a prison or jail setting. Alternatives to incarceration (ATI) that focus on treatment and rehabilitation within the community, particularly for drug-involved offenders, are just such strategies.Footnote 3 In addition to providing treatment, ATIs have shown promise in reducing recidivism and crime; appropriate use of ATI strategies has the potential to relieve over-crowding in jails and prisons and there is evidence that some ATIs, such as drug courts, may be more cost effective than incarceration (National Institute of Justice, 2006). Furthermore, women’s engagement in ATI programming rather than incarceration may serve to reduce familial disruption and the other negative consequences associated with maternal incarceration (National Institute of Justice, 2006).

Somewhat surprisingly, the women in this study overwhelmingly reported having positive relationships with their parole/probation officers. Participants characterized their parole/probation officers as being understanding and concerned with their welfare. Moreover, the women found their parole/probation officers to be reliable sources for service referrals. In speaking about her parole/probation officer, one woman indicated,

I’m glad for my parole officer…it feels good to be clean and sober and to me she was just an angel to save me…

While it is possible that this finding is largely a function of the jurisdiction and the organizational culture and goals of the probation departments from which the women were recruited, it does suggest that parole/probation officers may function as an important source of social support for these women. Parole/probation officers play a pivotal role in assisting women in finding appropriate services and supporting their regular attendance and engagement in psychosocial interventions.

Barriers to Employment

There is considerable evidence linking crime and unemployment and/or under employment and recidivism (Raphael & Winter-Ember, 2001; Sampson & Laub, 1993; Western, Kling, & Weiman, 2001a, 2001b). For women in particular, legitimate employment may represent a path to self-sufficiency and a life unencumbered by drugs and crime. Within this context, employment emerged as a major factor which is likely to complicate women’s ability to fully engage in psychosocial interventions as well as generally making their participation in “straight life” difficult. Four employment sub-themes were identified within the data: a) the role that a criminal record plays in securing employment; b) the lack of training, education or life skills appropriate for desired employment; c) inadequate transportation and/or the location of employment; and d) prior engagement in sex trading.

The role that a Criminal Record Plays in Securing Employment

Criminal justice involvement, specifically arrest, conviction, and incarceration, have been consistently linked to negative labor market consequence in the form of unemployment, under-employment, and low earnings (Western et al., 2001a, 2001b). The experience of the women in this study, described in the excerpts below, further substantiate these findings:

…some of us with felonies, it’s hard far us to find a job.

I’ve had jobs, but I guess that’s probably because they didn’t really hit the police report. I was just lucky that they overlooked it that time.

…even if you worked, or try to find jobs, the stigma of being on parole or probation knocks you down, you’re gonna get nothing.

I have a robbery charge so that means I’m automatically out of dealing with any type of money. And that’s what I’ve mostly dealt with is money. That’s a really serious charge, and it’s nothing that a lot of employers would overlook.

It is perhaps of little surprise that research has found that when employers are presented with job applications with and without reported criminal records, employers responded less positively to those applicants with a criminal record (Boshier & Johnson, 1974; Buikhuisen & Dijksterhuis, 1971; Western et al., 2001a, 2001b). Moreover, depending on the exact charge, the women’s ability to gain employment in certain areas, such as working a cash register in a fast food restaurant, an area that has historically provided employment to low-skilled workers, may be greatly restricted.

Lack of Training, Education or Life Skills Appropriate for Desired Employment

The excerpt below reflects the sentiments of many of the women who participated in the focus groups and their keen awareness that they are ill prepared to participate in the current job market:

Today my main problem is this, education, period… I feel like we should have better education programs for the ladies. Because the men have it all, but us women who are just fresh getting out and trying to start a new life it’s hard, especially with felonies, it’s hard to get jobs, it’s hard to go to a job and get a decent interview that’s really paying something because they want you to have education and if you’ve been in penitentiary you ain’t been doing no education… Once you get out of [name of prison] or whatever penitentiary you are in, what can you do if you ain’t got the education, you know the skills that you need to live in the proper society that you want to live in? If you ain’t got the education, you can’t get that pay to live there [in the free world], that’s what it’s about today. We need more education programs and we have to dig deep to look for them cause it’s not going to come for us…

Securing employment with a criminal record is further compounded by the women’s lack of education and/or training and life skills appropriate for the available jobs. Drug-involved female inmates are less likely than female inmates not involved in drugs to have worked prior to incarceration (Peugh & Belenko, 1999). Moreover, as indicated by the previous excerpt, women are generally not provided with vocational training while incarcerated. The majority of reentering women will not have participated in vocational, rehabilitative, mental health, or other types of programming while incarcerated, nor will they have this opportunity upon release into the community (Lynch & Sabol, 2001; Petersilia, 2003). This is particularly concerning given that adult basic education programs have shown promise in reducing recidivism and that correctional industries, vocational education, and community employment services are effective, if only minimally, in reducing recidivism (MacKenzie & Hickman, 1998; also see Gallagher, MacKenzie, & Wilson, 2000, for an excellent review of adult basic education programs).

Lack of Transportation and Location of Employment

Further complicating the issue of employment and employability for the participants in our study was the lack of adequate transportation (public or personal) and the location of employment opportunities:

Looking for work is hard because the best jobs are on the outskirts of town…there’s no bus service…The jobs are there, but how do you get to them?

The community in which this study was conducted is similar to many other moderately sized urban areas in this country in that the bulk of employment opportunities have shifted toward the suburbs, making travel from the central city a necessity. Unfortunately, public transportation systems have not kept up with the geographical shift of employment opportunities. Women in this study noted that there were too few bus routes to the suburban areas, the wait between buses was long, and travel times could exceed two hours. The systematic neglect of public transportation in many cities has further compounded the challenges faced by people of color, resulting in what has been referred to as “transportation racism” (Bullard, Johnson & Torres, 2004).

Trading Sex

Finally, the issue of prior engagement in sex trading was identified as a sub-theme related to employment. Although there is a well-established connection between illicit drug use and women’s engagement in trading sex for drugs, money or other commodities (Johnston, Callon, Li, Wood, & Kerr, 2010; Logan, Cole, & Leukefeld, 2003; Logan & Leukefeld, 2000; Reuben, Serio-Chapman, Welsh, Matens, & Sherman, 2011; Surratt & Inciardi, 2003), the apparent extent of these participants’ involvement in sex trading was a surprising findingFootnote 4:

Tricking is a way a woman says ‘I’m making my own money doing what I can do for myself’…

…I did not need a man to take care of me and I always had money to buy whatever drugs I needed, or to do whatever I wanted

Discussion of engagement in sex trading appeared to center on the contrast between the relative ease by which women could earn money (or other commodities) through this behavior compared to the difficulties they were currently experiencing trying to find and retain legal employment and earn money. As indicated in the words of the woman below, the temptation to engage in sex trading, even during periods of abstinence from drugs, appeared to be compounded by their current employment difficulties:

Before I got in recovery I prided myself on that [work as a prostitute]. Um, I had probably about seven or eight tricks that I would mess with and I got paid well. Really, really, well. I prided myself on that cause I did not need a man to take care of me and I always had money to buy whatever drugs I needed, or to do whatever I wanted. And then once I did get into recovery, still to this day, everyday, you know when you have to count change for a pack of cigarettes it’s very humbling, it goes through my mind, but now I’m married and it’s like, ‘Well, I don’t want to do that today, no I just really, really don’t want to do that today.’ I don’t want to get that type of mind frame, I see the wrong in it today. But if I had to, if that’s what I would have to do to pay my rent or to eat I would, I would in a heartbeat.

In summary, employment was a central theme in the women’s discussions. The issues that were identified in this research, as well as the established connection between unemployment, crime, and recidivism, strongly suggest that stable employment is an important element in women’s ability to engage in treatment and maintain a drug- and crime-free lifestyle. A complicated interplay of personal (i.e., criminal record; educational history) and environmental (i.e., geographical location of jobs; employer preferences) factors influence women’s ability to secure employment. Interventions designed to address the needs of women in the criminal justice system must incorporate capacity building strategies that facilitate increased educational and job skill attainment, as well as actual employment assistance.

The Need for Safe and Affordable Housing

The need for safe, affordable, and stable housing was a consistent theme among women in the focus groups:

I’m trying to get my children, they’re at their fathers right now because I don’t have anywhere to live, and in order to go ahead and have primary custody returned back to me I’m going to have to have an apartment. But even if I go to work it’ll be barely, barely enough, probably not enough to have a three or four bedroom apartment, pay the utilities, and have everything the children need, you know? And there won’t be any programs, they’ll say ‘You make too much because you have a job,’ but if you don’t have a job and they give you money then you don’t have enough to pay for it that way either.

Most people, if they’re not in a transitional house for women and children on drug addiction, they live with family members or somebody, a friend, or something where they’re always asked to be, after a certain limit of time, “You got to go, you got to go, you got to go.” Moving on and on and that pushes you right back out to the wolves.

While this finding may have been a function of the venues from which the women were recruited, homelessness and criminal justice involvement are nevertheless inextricably linked(National Health Care for the Homeless Council, 2007). As much as 56% of the homeless population has spent some time incarcerated; homeless people are more frequently arrested, incarcerated longer; and re-arrested at higher rates than people with stable housing (National Health Care for the Homeless Council 2007). Moreover, there are specific housing penalties associated with both women’s criminal justice involvement and substance use that make securing stable housing even more challenging for this population:

My experience has been, I was receiving HUD and I became a convicted felon while I was receiving it and they kicked me off HUD and I’m not eligible for five years….

This participant refers to one-strike policies that were implemented in the 1990’s to reduce drug-related crime. These policies allowed for the exclusion of prospective or current public housing tenantsFootnote 5 who had certain types of drug convictions, were using illegal drugs (even if they had no criminal record), or were viewed as a “threat” by the housing authority (for a full discussion of the one-strike policies see Human Rights Watch, 2004). Overall, the effect of these policies has been to exclude a wide swath of needy women from public housing (Human Rights Watch, 2004).

In addition to the housing penalties associated with a criminal and/or drug using history, the women also identified the challenge and frustration of finding affordable housing in safe and desirable neighborhoods. The actual environment in which women must live their daily lives is an important factor to take into consideration:

…there isn’t anything available…and if there is, it’s in a neighborhood that is so bad and drug infested and gang related that you don’t even need to go there.

The prevalence of both drugs and crime in close proximity to the women’s daily activities may act as powerful triggers for substance use or other illegal activity.

Finally, women reported being sent to multiple agencies and given outdated service referrals in their attempts to secure housing and other services:

They say, ‘Well, there’s other official offices around town that can help you…all we do is this,’ but yet they don’t even know where to tell you to go.

…and she [agency worker] gave me this paper for numbers to different agencies, places for housing and assistance with different things, and over half of the numbers that were listed were wrong, they were disconnected.

Women who are dealing with circumstances that have stretched their internal and external resources to their limits are routinely confronted with complicated and fragmented social service systems that do little to assist them with securing stable housing or other needed services. Indeed, the challenge of locating safe, affordable, and stable housing, in addition to previously addressed employment issues, underscores the necessity of service system coordination. These findings suggest a need for an intensive case management component within psychosocial interventions designed for this population.

Assertive community treatment (ACT) is a model of comprehensive community-based psychiatric care for persons with serious mental illness (Phillips et al., 2001; Stein & Santos, 1998). The ACT model utilizes a multi-disciplinary team to provide psychiatric care, case management, employment, housing, and other necessary services that allow clients to successfully remain in the community. This approach may represent a promising option to address both housing and employment needs as well as ongoing service fragmentation among women in the criminal justice system. Among individuals with mental illness, ACT has been shown to be effective in reducing psychiatric hospitalizations, facilitating a higher level of housing stability, and reducing substance use—issues that clearly affect women in the criminal justice system (Phillips et al., 2001). In fact, ACT has been successfully adapted to address the multitude of needs faced by persons with mental illnesses who are released from jail and are at risk for psychiatric hospitalization and/or re-arrest and incarceration (McCoy, Roberts, Hanrahan, Clay, & Luchins, 2004). In particular, among adults with serious mental illness reentering the community after incarceration in jail, the use of the ACT model was found to decrease re-arrests, increase residential stability, and reduce substance using behavior (McCoy et al., 2004).

The Pervasive Influence of Substance Use

Though substance use is interwoven with previously discussed themes, the pervasive influence of substance use in the lives of the women warrants an independent discussion. Two significant sub-themes emerged from the data: chronicity of substance use and the wide range of substance-related trauma and abuse experiences.

There is increasing evidence that substance use is a chronic condition whereby multiple treatment admissions over many years can be expected (Dennis, Scott, Funk, & Foss, 2005). McClellan, Lewis, O’Brien & Kleber 2000 have demonstrated that substance dependence and other chronic health conditions such as type 2 diabetes, hypertension, and asthma are similar in that they all are heritable, have a predictable etiology, and may require time-unlimited treatment. Within this context, it is perhaps not surprising that the chronicity of substance use emerged as an important issue in the women’s lives. The women‘s narratives indicated lengthy substance use histories, punctuated with multiple treatment attempts:

…I’m a suffering addict, who has had a lot of consequences in my life due to my addiction and my addictive behavior… I’ve been to seven treatment centers, my drug of choice is crack cocaine and marijuana, basically anything that makes me feel good…

Recent research examining addiction and treatment careers suggests that while brief interventions are effective for initiating change or treatment (re)entry, emphasis on continuing care and long-term recovery management is needed in order to sustain recovery for those with chronic substance use problems (Dennis et al., 2005). Research on the effectiveness of correctional drug abuse treatment has also echoed these findings. Specifically, a great deal of research supports the effectiveness of multi-stage therapeutic communities (TC; i.e. prison-based TC followed by community based in-patient treatment; and finally, community based out-patient treatment) in reducing substance use and subsequent recidivism (Golder et al., 2005). Moreover, this research indicates that increased time in treatment, specifically the increase in time between 5 months to 11 months, appears to be associated with the greatest effect on substance use and recidivism (Golder et al., 2005). Taken together, this research indicates that psychosocial interventions for this population need to identify the desired behavioral outcome (e.g. treatment entry vs. long-term recovery) and provide intervention/programming of adequate intensity and duration (e.g. combining in-patient and out-patient treatment over the course of 5 to 11 months).

Relatedly, the women acknowledged and identified a number of different traumatic events they had experienced. These events ranged from violence and victimization to the loss of custody of minor children. Importantly, the women identified trauma events as both stemming from and causative of further substance use. Excerpts from different participants illustrating this point are included below. These quotes provide further illustration of the significant overlap between victimization, mental disorders and substance use among this population:

A lot of my personal stuff is being so high and finding out that your daughter has cocaine in her system and you don’t know how it got there. Not only things that you’ve done to other people, but stuff that’s happened to you. You know, through your family, being sexually molested and dealing with a lot of different issues like that.

…I’ll start by saying I’ve got seven children and all of them have been taken out of my custody. So I’ve had some clean time, I could stay clean a good 15 months, but it’s the feeling of having been torn apart and trying to get them back together and the feelings become overwhelming. Then there’s one that’s been adopted, my rights have been terminated and when their birthdays come around and the other children ask about her… I think it’s at least four of them that don’t even know her personally…

And it took a lot to get me here ladies, I took a lot, abuse, pimping, prostitution, losing loved ones, every single one in my life, being brutally beaten, brutally raped, you name it I’ve done it, period.

Limitations

Due to the sensitive nature of the focus group content, a decision was made not to collect demographic information from the study participants. While this decision seemed to make the women more comfortable and enhance recruitment and participation, it disallowed a demographic description of the sample, including length of or types (i.e., probation versus parole) of criminal justice involvement. A description of the larger population of women on probation and parole in the city where the focus groups were conducted is available by contacting the first author.

Implications and Recommendations

Together, the conceptually guided review of women’s psychological needs, as well as the focus group findings provide a number of indications for programming and intervention development for this population. In the following section we enumerate additional suggestions and guidelines for programming and intervention drawn from this research and supplemented with guidance from prior related research. Some recommendations may be accommodated by altering existing approaches; others, however, will require a more substantial restructuring of services to better reflect the unique needs of women.

Integrated Programming and Intervention Models

Given the high prevalence and interrelated nature of victimization, substance use and other mental disorders among women in the criminal justice system, comprehensive assessment and integrated treatment should be features of all programs and interventions. The following guidelines for implementing and developing integrated intervention models for women in the criminal justice system have been adapted from recommendations provided by the trauma workgroup of the WCDVS (Markoff, Reed, Fallot, Elliott, & Bjelajac, 2005):

  • Practitioners and administrators need to be knowledgeable of the complex interplay between victimization, substance use and other mental disorders among this population. Women’s symptoms need to be understood within a single conceptual framework.

  • Programming and intervention should strive to create emotionally and physically safe environments for women in the criminal justice system. Women should be allowed to set the pace and goals for their treatment. Cognitive-behavioral approaches should be incorporated to help women understand their triggers (for substance use and trauma related symptoms [e.g., panic attacks; flashbacks; emotional flooding). Skill building and educational components that allow women to gain mastery in recognizing, managing, and reducing their trauma symptoms should be incorporated into interventions. Current safety (particularly for women sanctioned in the community) is also a paramount concern. Safety checks may be included in individual and group sessions on a regular basis and safety planning should integrated into each woman’s treatment plan (Gilbert et al., 2006).

  • Women should receive advance notice of the consequences of behaviors that are inconsistent with the programs goals. For example, a positive urine toxicology may result in immediate rearrest and incarceration. The use of restraints (physical or chemical) or other types of sanctions (e.g. isolation; suicide watch) could be retraumatizing for women and should be limited to the most extreme circumstances.

  • Confidentiality is an important consideration within the criminal justice system and attention needs to be given to the procedures for gathering, keeping and sharing information. Limits on confidentiality need to be made explicit; reports or evaluations that are released to other agencies/professionals should be made available to the woman as well.

  • Intervention strategies that begin with aggressive outreach efforts may be a more effective at targeting and engaging drug- and crime-involved women. Outreach has been identified as a particularly useful public health strategy for addressing the needs of high-risk populations (Tembreull & Schaffer, 2005). The inclusion of outreach components into traditional intervention models may be an especially effective way to reach drug-involved women within the criminal justice system, particularly those women who are not required to see a probation or parole officer on a regular basis.

  • Peer-led components are an affordable and important addition to programming and intervention. Such efforts may include support groups (e.g. 12-step groups such as Alcoholics Anonymous [AA], Narcotics Anonymous [NA]), workshops to promote health and well-being (e.g. relapse prevention), and more informal activities such as art and exercise. Peer-led components help reduce stigma and increase self-esteem, increase perceptions of social support, facilitate the development of responsibility and leadership.

Intervention Should Comprehensively Address Psychological and Social Needs

Integrated treatment of victimization, substance use and other mental disorders is more effective than treatment as usual (Clark & Power, 2005; Cocozza et al., 2005), though best-practice programs will have limited efficacy if the social or environmental challenges facing women in the criminal justice system are not addressed. Women in the criminal justice system must attend to immediate needs such as food and shelter before they can address distal issues (e.g., depression; (El-Bassel, Ivanoff, Schilling, Gilbert, Borne & Chen 1995). Comprehensive intervention models for women in the criminal justice system should include components that are designed to address the woman’s pressing social needs, including: promoting educational attainment, providing job training, offering employment assistance, and providing assistance in accessing safe and affordable housing.

Woman in Environment

Research demonstrates a cyclical pattern of involvement in the criminal justice system whereby many women move between arrest, incarceration, and the community. The vast majority of women who are incarcerated will eventually return to their communities (Greenfeld & Snell, 1999). Nearly two thirds of female state inmates have a past conviction and there is a 52% rearrest rate for women at 3 years post-discharge from prison (Greenfeld & Snell, 1999). This pattern of institutional and community engagement should be accounted for in programming and interventions designed to be delivered within prisons and jails. Rather than viewing treatment within correctional institutions as discrete events, programming should be part of a larger continuum of care that moves with women from the institution into the community (e.g. Lipton, Pearson, Cleland, & Yee, 2003; Martin, Butzin, Saum, & Inciardi, 1999; Prendergast, Hall, Wexler, Melnick, & Cao, 2004). The Assess, Plan, Identify, and Coordinate (APIC) model, a best practices model for treating mentally ill jail detainees through comprehensive transition planning, may be adapted to provide practitioners and administrators guidance in developing appropriate transitional and reentry plans for women in the criminal justice system (Osher, Steadman, & Barr, 2003).

Service System Coordination

The depth and breadth of the psychosocial challenges of women in the criminal justice system, as well as the need to address women from the institution to the community, necessitates the inclusion of service system coordination. Thus, case management must be an essential element of programming and intervention design for this population. Case management is a coordinated approach to service delivery and links clients with appropriate services to address specific needs and achieve stated goals (SAMHSA, 1998). SAMHSA provides guidelines for comprehensive case management for substance abuse treatment that can be adapted to guide program and intervention development and train staff who work with women in the criminal justice system (SAMHSA, 1998). In addition, specific case management models such as the previously described ACT model may be effective and appropriate for work with this population (McCoy et al., 2004; Stein & Santos, 1998; Phillips et al., 2001).

Intensity and Duration

Finally, given the long and entrenched histories of victimization, substance use and other mental disorders among women in the criminal justice system, service delivery and treatment must be of adequate intensity and duration to affect lasting behavioral change. Intensive programs are defined as those that occupy 40% to 70% of an offender’s time in prison (Gendreau & Ross, 1987), and findings from related areas of research suggest the optimal duration of treatment to be between 5 and 11 months (Lipton et al., 2003). This level of intensity and duration more accurately reflect the current understanding of substance dependence as a brain disorder (Volkow, Fowler, & Wang, 2004) that is often chronic and relapsing in nature (McClellan et al. (2000)).

Conclusion

The number of women involved in the criminal justice system is growing at a rapid rate. Programming and interventions that reduce women’s involvement in the criminal justice system and ameliorate the negative consequences associated with criminal justice involvement are urgently needed. Though women in the criminal justice system have unique needs, the majority of existing programming for women consists of services designed for men. Programs and interventions for women need to be adapted to better address the interrelated problems of substance use, victimization, and mental health disorders. Additionally, there is a need to develop comprehensive and time-unlimited programs that better reflect the challenges women encounter in the community. Finally, engaging women involved in the criminal justice system is contingent upon addressing the immediate needs of financial stability, housing, and family issues. The research reported herein provides practitioners, administrators, and policy makers with concrete, evidence-based strategies for addressing the most pressing psychosocial needs of this population.