For years, practitioners in just about every field took research conducted primarily with male subjects and applied the findings to women. Recently, however, researchers have begun to question the applicability of those findings to women-and the answer has been mixed.
One area in which the applicability of gender-neutral data has come under scrutiny is corrections. A recent report of the National Institute of Corrections states that, at the same time that the number of female inmates has been increasing significantly, the criminal justice system has too often—and with difficulty—tried to implement with women inmates “policies and procedures that…[were] designed for male offenders.” This practice may be ineffective because studies show that female inmates must overcome unique social, emotional, and physical challenges that impede their ability to integrate smoothly back into society following a period of incarceration.
Change is now well under way. Inmate rehabilitation programs are being developed specifically for female inmates. Older programs originally designed for male inmates are being evaluated to see how appropriate they are for incarcerated women.
NIJ studies looked at drug addiction treatment and other rehabilitation programs for female inmates in various jurisdictions. These studies point out the distinct treatment needs of female inmates and examine ways that programs addressing these unique requirements can help women successfully reenter society after incarceration.
The KEY/CREST Programs
The Delaware Criminal Justice Council received a grant from NIJ to evaluate the gender appropriateness of two therapeutic community drug rehabilitation programs: (1) The KEY program at Baylor Women's Correctional Institute and (2) CREST, a work release program at Sussex Correctional Institute.
Therapeutic Communities for Women
Prior research has shown that the therapeutic community model, originally designed for men, can be successful for women if modified. For example, the success of women in therapeutic community programs is increased when the atmosphere is less confrontational and when female counselors are present. Additionally, women bring with them a host of personal issues-such as a history of sexual abuse and problems in maintaining relationships with their children-that must be addressed. These problems are distinct from those usually faced by male drug addicts.
During implementation of the KEY program, researchers observed the need for aftercare to maintain the positive changes in KEY graduates. To meet this need, Delaware obtained funding in 1990 from the National Institute on Drug Abuse to establish the first work-release program (CREST) based on the therapeutic community model. Research since the implementation of KEY and CREST has found that addicts who attend both KEY and CREST have lower recidivism rates than those without KEY or CREST program experience.
Four Failure Factors
The report submitted by the Delaware Criminal Justice Council shows that of the various demographic and social factors affecting a woman who enters the KEY program, four will have the most impact on whether she will succeed. A female inmate is at higher risk of failure if she has any one of these four factors:
- She has a psychiatric history (formal diagnosis and/or emotional/psychological difficulties).
- She has contemplated suicide.
- She has attempted suicide.
- She has difficulty controlling her temper or her behavior is hostile or violent.
The Council's report demonstrates that the first 5 weeks are critical for a new KEY participant. If she is to fail, she will likely fail during this treatment orientation period. However, if she remains in the program through the 49th week (the midpoint of the treatment cycle), she will likely remain in the program and be successfully discharged from KEY.
The Criminal Justice Council contracted Beth Bonniwell Haslett of the University of Delaware to analyze the curriculum used in KEY and CREST and to assess the two programs. Haslett concluded that the programs were gender appropriate, but made two main recommendations:
- The CREST program should be made single-sex, like the KEY program at Baylor. Haslett observed that when women clients were interrupted or challenged by men, they often fell silent, which tended to hinder the therapeutic process.
- KEY and CREST should reassess the hierarchy structures of the programs to be more therapeutic for women. The imposition of strict rules and harsh consequences for breaking those rules may provide needed structures for males in rehabilitation programs, but women do better in an environment where support and encouragement are emphasized.
What Participants Had to Say
When asked, program clients considered the programs gender appropriate overall, but many expressed a wish that the programs have more female-only encounter groups. They also thought there should be more programming to help addicts make peace with their families and maintain contact with their children. Although Haslett recommends that the programs be made single-sex, participants thought that the coed nature of the CREST program was a benefit, providing an opportunity to develop healthy and positive attitudes and behaviors toward the opposite sex. This view was shared by program directors.
A difference of opinion emerged concerning the confrontational aspects of the programs, in which participants can challenge each other's behavior. Many women, citing histories of family violence, did not like the shouting and verbal sparring that often resulted from these parts of the programs. Some complained that there was more "tearing up" than "building up." Older women tended to be more uncomfortable with confrontation and felt "disrespected" when challenged by younger peers. Many thought more emphasis should be placed on bonding among participants and less on confrontation. (Program directors cited the potential for sexual activity and dependency as the reason that relationship building is limited and controlled in these programs.) The women generally viewed the programs' strict rules as providing structure and instilling the idea that the world outside had rules that had to be followed.
Most participants agreed that the programs offer an addict a way to "straighten up" and that, in the end, the addict has to want to change for the programs to work.
The Forever Free Program is a voluntary, intensive residential treatment program for women inmates with substance abuse problems at the California Institution for Women in Corona, California. The residential program is followed by voluntary community residential treatment during parole. Forever Free began as a 4-month program and has since returned to that duration; at the time of this evaluation, however, it was briefly extended into a 6-month program.
Forever Free stresses relapse prevention and approaches addiction as a disease. It also teaches offenders to identify symptoms and develop unique skills and strategies for dealing with withdrawal.
Some sessions are devoted to issues especially important to women's recovery, including self-esteem, anger management, assertiveness training, healthy relationships, physical and psychological abuse, posttraumatic stress disorder, codependency, parenting, sex, and health.
Women participating in the Forever Free Program were compared with women attending Life Plan for Recovery, an 8-week substance abuse education course. This group was chosen for comparison because participants had similar backgrounds and demographics and similar motivation for treatment (voluntary participation in substance abuse education). The women in both groups were about 35 years of age and averaged about 16 prior arrests and 8 prior incarcerations. Most had been incarcerated for a drug offense. In addition, they were poor, ethnically diverse, undereducated, and they worked in low paying jobs.
The study demonstrates the effectiveness of the Forever Free Program for women offenders both in terms of their involvement in the criminal justice system and in other aspects of their postrelease lives (e.g., employment, relationships with children, and services needed and received). Women in both the treatment and comparison groups were followed up 1 year after release.
Criminal justice measures. Forever Free Program participants reported being rearrested and/or convicted at a significantly lower rate than participants in the comparison group (40 percent versus 60 percent).
Drug use. In contrast to the comparison group, a significantly lower percentage of Forever Free participants reported any drug use since release from custody (51 percent versus 77 percent).
Employment. Two-thirds of Forever Free participants were employed at the time of the followup interview compared to less than half of the comparison group. Participating in residential treatment during parole apparently improved all subjects' chances of being employed.
Psychological functioning. At the 1-year followup, Forever Free participants had significantly better psychological functioning than members of the comparison group.
Treatment motivation and treatment attendance. Postrelease interviews revealed that drugs were a greater problem for the comparison group than for the Forever Free participants. Members of the comparison group also had a greater desire for additional help than the treatment group. However, Forever Free participants felt that they had greater control over their drug-use behaviors.
Relationships with children. In contrast with the comparison group, a larger number of Forever Free women had custody of all of their children postincarceration (48 percent versus 28 percent). Twice as many Forever Free women rated themselves as doing well in their parenting than did members of the comparison group.
Services needed during parole. Women in the comparison group reported greater needs for services than the Forever Free group. These services included transportation, medical treatment, life skills training, and vocational training. The Forever Free group appeared much better able to obtain such services for themselves.
Another significant finding of the Forever Free study is the importance of treatment after release from custody. For example, women who attended community residential treatment were much more likely to be employed at followup. In light of this evidence, criminal justice system policymakers may consider encouraging community residential aftercare for women participating in prison-based treatment programs for drug abuse.
This study demonstrates the effectiveness of the Forever Free Program for women. And while most therapeutic community treatment programs last 12 months, the Forever Free Program lasts only 4 months (although it lasted 6 months at the time of this study). The fact that the program was able to demonstrate its effectiveness in a shorter time period than most programs may indicate that other programs could replicate Forever Free's success rate by emulating its curriculum-and save valuable tax dollars in the process.
Some incarcerated women receive a dual diagnosis of substance use disorder and posttraumatic stress disorder (PTSD). PTSD can be recognized in women with extensive histories of interpersonal violence. PTSD can compound the effects of substance abuse and increase the chance of criminal recidivism.
Seeking Safety is a cognitive-behavioral treatment developed in 1992 by Lisa Najavits at Harvard Medical School/McLean Hospital. It is designed for people dealing with both substance use disorder and PTSD or other trauma-related symptoms. Seeking Safety is a flexible treatment that can be used for men and women, in group or individual therapy settings, in outpatient or residential treatment facilities. Sessions focus on developing skills designed to combat both substance addiction and PTSD. For example, distraction techniques can be used to calm the triggers of both drug abuse and PTSD. The goal is to help clients attain a sense of self-control that will avert dangers in their behavior (e.g., self-inflicted injury), in their relationships (e.g., the risk of HIV infection), and in their thinking (e.g., addiction-related cognitive distortions).
The NIJ-funded study evaluated the initial impact of this approach in a group of women inmates in the Discovery Program, a substance abuse program at the Adult Correctional Institute in Rhode Island. There were two pilot studies. One pilot study involved six inmates who received Seeking Safety treatment. The other study involved participants who were randomly assigned either to a control group of 10 women who received treatment as usual or an experimental group of 12 women who received Seeking Safety treatment as an adjunct to treatment as usual.
Researchers conducted assessments pretreatment, posttreatment during incarceration, and postrelease. Preliminary findings from the group of six women are promising. In particular, these women showed a significant improvement in PTSD symptoms at posttreatment as well as at 6 and 12 weeks postrelease. Three of the six women no longer met the criteria for PTSD 3 months after treatment-a significant finding given that most individuals who receive treatment for PTSD take, on average, 36 months to recover from this disorder.
However, the random assignment study finds no differences between the test and control groups on any of the indices of interest (including PTSD symptoms, drug use, and recidivism). Significant differences between the Seeking Safety treatment group and the treatment-as-usual group were likely difficult to detect due to the small size of the control group and an appreciable attrition rate (30 percent) within the group.
The finding that 33 percent of the women who received Seeking Safety treatment returned to prison 3 months postrelease and that women in the treatment group were more likely than members of the control group to return to prison (50 percent versus 10 percent) may be explained by the fact that members of the treatment group had a greater severity of drug use than did members of the control group prior to entering prison, putting the treatment group at greater risk for recidivism. These findings also indicate that women who received Seeking Safety treatment may not have successfully transferred skills learned in the program once they left incarceration and reentered the community. Further investigation is needed to determine whether an extension of the Seeking Safety treatment to the postrelease period might improve on the treatment program's effectiveness in reducing recidivism.
The Rhode Island Programs
Another study on the appropriateness of rehabilitation programs for female inmates examined discharge planning offered by the Rhode Island Department of Corrections (RIDOC). RIDOC offers female inmates programs addressing substance abuse, education and job training, life skills training, and emotional and mental health.
The study finds that the programs at RIDOC appear to be successfully matched to the needs of the steadily increasing population of female inmates. Programs are staffed by culturally diverse female role models who participate in both staff and mentoring programs. The programs offer drug treatment and multidimensional strategies for decision-making and skillbuilding, which are generally recognized as beneficial to women inmates. The programs are well received and well attended-most women inmates (more than 70 percent) participate in at least one type of program.
Overall, the results of the evaluation demonstrate that the RIDOC programs produce some positive changes in incarcerated women, such as increased confidence in life skills and reduced substance use. Women who received counseling in both areas were the most likely to believe they could get and keep a job and avoid subsequent substance abuse problems. However, none of the programs was able to reduce recidivism. Problems encountered by the women after release-such as an abusive partner-can overwhelm changes made prior to release. More than one-third of the women left prison with no job, no formal job training, no source of income, and less than a high school education, placing them at a further disadvantage. Moreover, many women who were recidivists were generally ill-equipped to deal with the routine stresses of daily life in the community and required strong social support upon release from prison. Supervised transition settings safe from violent partners, with opportunities to practice skills learned in prison, may be appropriate.
Recognizing the Need for a Different Approach
Though the various treatment programs discussed in this article differ in their details and approaches, all share the premise that the needs of women inmates differ in many respects-physically, emotionally, psychologically, and socially-from those of their male counterparts. The implementation of rehabilitation programs specifically designed with those differences in mind can effectively address the needs of female inmates and identify factors which may impede their ability to succeed post release.
About This Article
This article appeared in NIJ Journal Issue 252, July 2005.
This article is based on four studies conducted for NIJ. The names of the study authors and their reports are:
Garrison, Arthur, Process Evaluation Assessing the Gender Appropriateness of the KEY/CREST Program, Final Report to NIJ, grant number 99-RT-VX-K016, April 2002 (NCJ 195788). The full report and Executive Summary are available from NCJRS (https://www.ncjrs.gov/pdffiles1/nij/grants/195788.pdf). Garrison is the director of criminal justice planning for the Delaware Criminal Justice Council.
Prendergast, Michael, Elizabeth Hall, and Jean Wellisch, Outcome Evaluation of the Forever Free Substance Abuse Treatment Program: One-Year Postrelease Outcomes, Final Report to NIJ, grant number 99-RT-VX-K003, December 2001 (revised July 2002) (NCJ 199685). The full report and Executive Summary are available from NCJRS (https://www.ncjrs.gov/pdffiles1/nij/grants/199685.pdf). Prendergast and Hall are researchers at the University of California-Los Angeles Integrated Substance Abuse Programs, Criminal Justice Research Group. Wellisch is an independent consultant specializing in program evaluation and policy formulation.
Quina, Kathryn, Collaborative Development of Individual Discharge Planning for Incarcerated Women, Final Report to NIJ, grant number 96-CE-VX-0012, December 2000 (NCJ 191202). The full report is available from NCJRS (https://www.ncjrs.gov/pdffiles1/nij/grants/191202.pdf) as is the Executive Summary (https://www.ncjrs.gov/pdffiles1/nij/grants/191195.pdf). Quina is a professor of psychology and women's studies at the University of Rhode Island.
Zlotnick, Caron, Treatment of Incarcerated Women With Substance Abuse and Posttraumatic Stress Disorder, Final Report to NIJ, grant number 99-WT-VX-0004, July 2002 (NCJ 195165). The full report is available from NCJRS (https://www.ncjrs.gov/pdffiles1/nij/grants/195165.pdf). Zlotnick is an associate professor in the Department of Psychiatry and Human Behavior at Brown Medical School.
 Bloom, Barbara, Barbara Owen, and Stephanie Covington, Gender-Responsive Strategies: Research, Practice, and Guiding Principles for Women Offenders, Washington, DC: U.S. Department of Justice, National Institute of Corrections, June 2003.
NIJ Journal Issue No. 252
NIJ Journal, Jul 2005
Process Evaluation Assessing the Gender Appropriateness of the KEY/CREST Program, Final Report
Outcome Evaluation of the Forever Free Substance Abuse Treatment Program: One-Year Post-Release Outcomes
Collaborative Development of Individual Discharge Planning for Incarcerated Women, Final Report