UCLA Integrated Substance Abuse Programs Gender-Responsive Drug Treatment Services for Women Offenders Elizabeth Hall, Ph.D. Criminal Justice Research Group Integrated Substance Abuse Programs Semel Institute for Neuroscience and Human Behavior University of California, Los Angeles Research funded by the National Institute of Justice, the California Department of Corrections and Rehabilitation, and the National Institute on Drug Abuse

UCLA Integrated Substance Abuse Programs Overview Discuss treatment and service needs of women drug offenders From an ongoing study:  Psychological functioning  Parenting  Social support  Adult relationships Describe gender-responsive treatment Describe the current state of research knowledge on gender-responsive treatment

UCLA Integrated Substance Abuse Programs Background: What are the characteristics of national and state populations of women in prison and on parole? Growing population  Increased by 21% from 2000 to 2006 to total of 103,100  just last year, the number of women prisoners increased by 4.5% from the previous year Mostly due to drug offenses  11% in 1979, nearly 35% in 1997, 30% in 2001, 29% in 2004  59% of women used drugs in the month prior to their offense  Female inmates (17%) were more likely than males (10%) to report use of methamphetamines in the month before their offense  Female inmates (60%) were more likely than males (53%) to meet drug dependence criteria  40% committed offense under the influence of drugs Underclass population  70 to 90% were unemployed, 50% were functionally illiterate, 42% had not completed high school or the GED prior to incarceration

UCLA Integrated Substance Abuse Programs Background: What does prior research say about women offenders’ need for health and mental health services upon release? Health  ~ 37% of women parolees report needing medical or dental services in the year after release Mental health  ~23% of women in jails and state prisons are mentally ill  High level of prior physical and sexual abuse  51% of women, and, 78% of mentally ill women in state prisons reported having been physically or sexually abused prior to incarceration  63% of mentally ill women released from prison received community mental health treatment; 19% were hospitalized (Massachusetts)

UCLA Integrated Substance Abuse Programs Background: What does prior research say about women offenders’ need for daily living services upon release? Welfare assistance  56% of women parolees received welfare assistance in the year after release Housing  9% of state prison inmates (men and women) were homeless in the year before incarceration  One-third of mentally ill women offenders were anticipating homelessness upon release

UCLA Integrated Substance Abuse Programs Background: What does prior research say about women offenders’ need for parenting assistance services? Family  Seven in ten women inmates had children under 18 years of age, and of these, two-thirds of the children were living with their mothers before incarceration  Responsibility for children may preclude residential treatment after release

UCLA Integrated Substance Abuse Programs Background: What does prior research say about women offenders’ need for vocational services? Less likely to have viable work skills or employment history, as compared with males Lower wages

UCLA Integrated Substance Abuse Programs Why have gender-responsive programs? Research suggests that women may be more responsive to treatment within women-only treatment facilities or groups, because they feel less intimidated or concerned about being stigmatized in such settings, because of a desire to obtain services specific to their needs, or because they seek shelter from intimate partner violence.

UCLA Integrated Substance Abuse Programs Characteristics of Gender-Responsive Programs Focus on the psychosocial profile of substance- abusing women Designed to meet need for comprehensive services pregnancy childcare and parenting physical and mental health problems employment and housing history of trauma and victimization

UCLA Integrated Substance Abuse Programs Is gender-responsive treatment successful? Research shows that women are more likely to complete treatment and have better outcomes when targeted services are available residential treatment with live-in accommodations for children provision of family therapy comprehensive supportive services, such as case management, pregnancy-related services, parenting training/classes, childcare, vocational training, and aftercare More research needs to be done

UCLA Integrated Substance Abuse Programs Evidence-based treatment approaches for women substance abusers Relapse prevention approaches focus on teaching clients to recognize “cues” or “triggers” for substance use and strategies for avoiding relapse in those situations Motivational interventions use therapeutic strategies to increase the individual’s awareness of their substance abuse problems and to engage their commitment to behavior change Contingency management approaches employ a schedule of rewards to strengthen the practice of desired behaviors (e.g., abstinence)

UCLA Integrated Substance Abuse Programs Evidence-based treatment approaches for women substance abusers, cont’d Trauma and PTSD interventions  Seeking Safety – cognitive-behavioral  Trauma Recovery and Empowerment Model – group therapy  Beyond Trauma – “relational theory”

UCLA Integrated Substance Abuse Programs Recommendations Drug courts should: refer women to treatment programs that are either focused exclusively on women clients or that provide services specifically tailored for women’s needs. make sure that mental health screening and assessment occurs for all women and, when indicated, that mental health treatment is integrated with addiction treatment ensure that treatment programs screen women for their history of trauma and the ongoing effects of exposure to trauma, violence, and victimization

UCLA Integrated Substance Abuse Programs Recommendations Drug courts should: assure that treatment programs provide services that address their need for education and employment skills ensure that parenting-related needs are assessed, and, if appropriate that treatment is coordinated with child welfare services refer women to treatment programs that screen for health problems commonly found among female substance abusers utilize treatment programs that incorporate evidence- based treatment approaches

UCLA Integrated Substance Abuse Programs Gender Responsive Treatment for Women Offenders Michael Prendergast, Ph.D. Nena Messina, Ph.D. Elizabeth Hall, Ph.D.

UCLA Integrated Substance Abuse Programs Gender Responsive Treatment for Women Offenders Los Angeles In Drug Court and Prop. 36 programs Average number of days in treatment for those who attended (n=47) (SD 84.6) Demographics (baseline)N = 57 Age (mean)38.1 (SD 10.7) Education (mean years)11.7 (SD 2.0) Lifetime arrests (mean)11.5 (SD 23.6) Age first arrested (mean)24.3 (SD 9.3) Marital status (% married or living together) 29.8 Employed (% working in 30 days before arrest) 17.5

UCLA Integrated Substance Abuse Programs Ethnicity (%) White31.6 Latina28.7 African American29.8 Have minor children (%)45.6 Primary drug (%) Alcohol5.3 Cocaine/crack28.1 Heroin/opiates10.5 Marijuana1.8 Methamphetamine38.6 Other15.8

UCLA Integrated Substance Abuse Programs Psychological and Social Functioning Scale Baseline (N=57) 12-Month (N=57) BSI Global Severity Index35.0 (SD 33.2)29.2 (SD 34.9) 1 ECRI dimensions (mean) Adult attachment anxiety4.2 (SD 1.2)3.9 (SD 1.2)* Adult attachment avoidance3.5 (SD 0.9)3.4 (SD 0.9) ECRI adult attachment styles (%) Secure Fearful Pre-occupied Dismissing Social support (mean)16.9 (SD 7.8)20.4 (SD 6.4)** 1 p<.10, *p<.05, **p<.01

UCLA Integrated Substance Abuse Programs Parenting Baseline (N=57) 12-Month (N=57) AAPI (parenting) STEN scores(N=26) Inappropriate expectations5.4 (SD 1.7)5.6 SD (1.3) Empathy1.0 (SD 0.2)1.1 (SD 0.6) Physical punishment1.8 (SD 1.2)1.8 (SD 1.1) Reverses family roles2.1 (SD 1.5)2.2 (SD 1.5) Restricts power/independence1.0 (SD 0.0)1.1 (SD 0.4)

UCLA Integrated Substance Abuse Programs Conclusions A minority of participants (16%) had a secure adult attachment style in which they found it easy to be emotionally close to others. While attachment styles did change over time, most notably a reduction in the percentage of women exhibiting a fearful attachment style (discomfort in getting close to others), the move to a dismissing attachment style (preferring not to depend on others or have others depend on them) was not a positive sign of growth. Participants showed personal growth in social support and improvement in their psychological symptoms.

UCLA Integrated Substance Abuse Programs Conclusions While participants had expectations for their children that were age-appropriate, they lacked empathy for their children, tended to favor physical punishment, tended toward parentification of their children (reversed roles), and tended toward an authoritarian relationship (restricting power/independence) with their children. Given the cyclical nature of abuse, the lack of improvement in parenting attitudes over time shows a high need among this population for additional parenting intervention.

UCLA Integrated Substance Abuse Programs Questions?

UCLA Integrated Substance Abuse Programs Gender-Responsive Drug Treatment Services for Women Offenders Elizabeth Hall, Ph.D. Michael L. Prendergast, Ph.D. Jean Wellisch, Ph.D. Criminal Justice Research Group Integrated Substance Abuse Programs Department of Psychiatry and Biobehavioral Sciences University of California, Los Angeles Research funded by the National Institute of Justice, the California Department of Corrections, and the National Institute on Drug Abuse

UCLA Integrated Substance Abuse Programs Background: Forever Free Substance Abuse Treatment Program Started in 1991 Designed specifically for women Cognitive-behavioral model (Gorski) Participants housed separately, but mix with other inmates during meals and work assignments Intensive six-month program provided to volunteering women inmates during the end of their imprisonment Upon release, women may also volunteer for an additional six months of residential treatment in the community

UCLA Integrated Substance Abuse Programs Aims Compare the post-release service needs of Forever Free participants with similar inmates from the general prison population Compare the post-release services received by Forever Free participants with similar inmates from the general prison population Determine the levels of unmet need for post-release services Examine changes in needs and services over time

UCLA Integrated Substance Abuse Programs Subjects Female 215 inmates  119 enrolled in Forever Free  96 in comparison group enrolled in drug education Housed at California Institution for Women near Chino Low educational attainment 66% have children under 18 Offenses were primarily drug or drug-related During the 30 days before incarceration, the treatment group reported spending an average of $125 on alcohol and $1,976 on illegal drugs

UCLA Integrated Substance Abuse Programs Methods In-prison assessment:  Twice for the treatment group  Once for the comparison group (abbreviated form) One-year post-release interviews:  Telephone and face-to-face  Urine samples Follow-up interviews were completed with 84% of the original sample.

UCLA Integrated Substance Abuse Programs Findings: Treatment post-release (percent) 1 1 p<.10 * p<.05 *** p<.001 * *** 1

UCLA Integrated Substance Abuse Programs Findings: Psychological functioning (mean score) *** *** p<.001 ***

UCLA Integrated Substance Abuse Programs Findings: Employment (percent) * * p<.05

UCLA Integrated Substance Abuse Programs Findings: Children’s status at follow up (percent) * * p<.05

UCLA Integrated Substance Abuse Programs Findings: Self-rating of how well doing as parent (percent) * * p<.05

UCLA Integrated Substance Abuse Programs Findings: Substance abuse treatment needs post-release (percent) *

UCLA Integrated Substance Abuse Programs Findings: Substance abuse treatment services received post-release (percent) *

UCLA Integrated Substance Abuse Programs Findings: Health and mental health services needs post-release (percent) *

UCLA Integrated Substance Abuse Programs Findings: Health and mental health services received post-release (percent) *

UCLA Integrated Substance Abuse Programs Findings: Daily living services needs post-release (percent) * * *

UCLA Integrated Substance Abuse Programs Findings: Daily living services received post-release (percent) **

UCLA Integrated Substance Abuse Programs Findings: Educational and vocational service needs post-release (percent) * *

UCLA Integrated Substance Abuse Programs Findings: Educational and vocational services received post-release (percent)

UCLA Integrated Substance Abuse Programs Findings: Parenting assistance needs post-release (percent) * *

UCLA Integrated Substance Abuse Programs Findings: Parenting assistance received post- release (percent)

UCLA Integrated Substance Abuse Programs Conclusions Women in both groups had a high need for services during parole Women in the comparison group generally had greater needs, but were less likely to receive services during parole The greatest unmet need for both groups was for vocational and educational services (37% - 40% service gap) Women also had a great unmet need for housing (35% service gap)

UCLA Integrated Substance Abuse Programs Discussion While previous national research found that custodial treatment programs report that they provide women offenders with treatment, housing, and welfare assistance; the percentage of women actually receiving such assistance may be small. Compared to previously reported research on an earlier group of Forever Free and comparison women, service needs have increased in all areas. Ask the women!

UCLA Integrated Substance Abuse Programs Ask the Women! We wanted to know about: Supports for success on parole Barriers to success on parole Why women didn’t enter treatment during parole Personal factors that may influence success

UCLA Integrated Substance Abuse Programs Method We conducted focus groups with 4 groups of women (all had received or were receiving drug treatment in prison): 1. Those about to parole 2. Those on parole and in community drug treatment 3. Those who paroled, got a new charge, and were returned to prison (Returnees) 4. Those who paroled and were long-term successes

UCLA Integrated Substance Abuse Programs What women learned in prison treatment:  “What I learned were things about myself - what’s inside. I learned that I don’t have to live like that anymore. I learned about self-esteem, post-acute withdrawal, etc.” [Rs]  “They teach us about abuse and relationships, about how it’s not our fault that we’re abused.” [Tx]  “I didn’t know I have an anger problem. They’ve taught me how to deal with my anger.” [Tx]

UCLA Integrated Substance Abuse Programs  “They help you realize that you aren’t that bad; that you have a lot of mistaken beliefs. You need to take a look at what you really are; that covered a lot of areas for me.” [LT]  “They explained why; just like elementary school; over and over again until you got it. But it was based on self-esteem. Conglomeration of a lot of different aspects. They really worked with you to make sure you really understood about all the different aspects of drug and alcohol use.” [LT] What women learned in prison treatment:

UCLA Integrated Substance Abuse Programs Treatment After Parole The greatest influence on parole success In addition to the basics of drug treatment, women got:  “unconditional love”  education  social and emotional support from counselors and other clients  networking experience  the 12 Steps

UCLA Integrated Substance Abuse Programs Concerns about finding employment:  No one wants to give you a chance if you’re an ex- offender. I couldn’t even get a job bagging groceries. [Tx]  They don’t tell you about certain things, like the difficulty of finding a job if you’re a felon. [LT]  The girls need some outlet for work. I finally got a job, but you need determination and a willingness to work for minimum wage. [LT]

UCLA Integrated Substance Abuse Programs Barriers to Success on Parole: Employment  You need resources, places to go. The CDC doesn’t provide you with anything. There is voc rehab through the parole agency, but you have to apply in advance. [LT]  Drug programs need job placement services. They need to help you educate yourself. There are all these computers here at [Program C] and they are going unused. [Res]  Residential programs need to inform us. We learn a lot of things here through word of mouth. A lot of us didn’t know about the Department of Voc Rehab, grants, schools, etc. and found out about them through other residents. [Program C] doesn’t help with job placement— they just tell you to go out and get a job. [Res]