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CHAPTER 10 Mental Health Needs of Female Offenders Ann Booker Loper and Lacey Levitt
Introduction There are more women in prison today than at any other point in U.S. history. The number of female offenders has climbed steadily since the early 1990s, with an increase of approximately 25% between the years 2000 and 2008 (Greenfeld & Snell, 1999; West & Sabol, 2009). Although still a minority compared to male offenders, the increasing presence of women in correctional settings raises the question, What is bringing women to prison? One early answer to this question was the simple one—with women becoming more liberated and therefore more “man-like,” they were increasingly emulating masculine behavior (Adler, 1975). However, this easy answer was quickly disputed by overwhelming evidence that the new brigade of women entering prison was anything but liberated. As a group, women in prison are poor, financially stressed, and tend to adhere to traditional role models of femininity (Bunch, Foley, & Urbina, 1983; Widom, 1979). Moreover, female patterns of offending do not resemble the patterns for men. Men account for more than 80% of the arrests for violent offenses, and proportionately fewer of the arrests of women are for violent crimes (Federal Bureau of Investigation, 2009). In the cases of violent offending committed by women, the gender patterns likewise differ: When a woman commits a violent offense, she is relatively more likely than a male to aggress against a family member or intimate, usually in the context of an emotional relational conflict (Loper & Cornell, 1996). Closer examination of the lives of women in prison reveals one obvious pathway—women in prison suffer from high levels of mental illness, substance abuse, and emotional distress, both before and during their time in prison, that can perpetuate criminal patterns. The heightened mental distress among a large portion of female offenders interacts with the broader societal changes in prison policies that have served to increase the entire prison population, such as abolition of parole, criminalization of drug possession, and stricter sentencing legislation. The net result is not only more women in prison today, but a population of women who face numerous emotional difficulties.
Mentally Ill Women in Prison: Why So Many? Prevalence of Mental Illness in Female Offenders Numerous women in prison experience mental illness (James & Glaze, 2006). Magaletta, Diamond, Faust, Daggett, and Camp (2009) documented several indicators of mental illness among approximately 2,900 newly committed federal offenders. For each indicator, women exceeded the rates among men. Relative to men, proportionately more female offenders suffered from a serious mental illness (9.6% versus 17.4%), had previously received inpatient psychiatric care (8.8% versus 15%), and had previously used psychotropic medications (11.4% versus 24.3%). This pattern of higher levels of mental illness among female offenders likewise extends to prison and jail populations (James & Glaze, 2006), as well as to offenders with known substance abuse problems (Zlotnick et al., 2008). As shown in Table 10.1, levels of mental illness among female offenders far exceed those found in population estimates of mental illness among women in the community (Lewis, 2006). Table 10.1 Lifetime Prevalence of Psychiatric Diagnosis in Female Offenders Disorder Source: Reprinted from ‘Treating Incarcerated Women: Gender Matters,’ by C. Lewis, 2006, Psychiatric Clinics of North America, 29, p. 777. aNewly admitted female felons. bFemale jail detainees. cFemale felons serving sentence. dNational sample of women in community. The high level of mental illness among female offenders begs the question, “Why?” Understanding mental illness among this population requires understanding the typically troubled histories of women who offend as well as the particular stressors of incarceration. What are the gendered experiences in the lives of female offenders that account for these high levels of mental illness? Childhood and Adult Victimization Childhood Maltreatment Although both men and women in prison report high levels of childhood maltreatment, the level of maltreatment and sexual abuse is generally higher among female offenders (Harlow, 1999; McClellan, Farabee, & Crouch, 1997; Messina, Grella, Burdon, & Prendergast, 2007). Greenfeld and Snell’s (1999) report on female offenders revealed that approximately 44% of women under correctional authority reported sexual or physical abuse at some time in their lives, typically before age 18. Browne, Miller, and Maguin (1999) reported similar findings of physical and sexual abuse after interviewing 150 incarcerated women at Bedford Hills Correctional Facility in New York State. Approximately 70% of the interviewed inmates reported instances of severe physical violence during childhood and adolescence, and nearly 60% revealed instances of sexual abuse prior to 18 years, perpetrated by someone at least 5 years their senior. Moreover, there appeared to be a relationship between childhood victimization and later adult victimization, as high levels of childhood trauma were associated with high levels of later domestic violence victimization. In one of the few prospective studies of the impact of child sexual abuse on offending, Siegel and Williams (2003) followed 206 women who, as children, had been treated in a hospital emergency room following a report of sexual abuse. Thus, unlike other studies that relied on the recollections of sexual abuse, this study was grounded in well-documented medical records. Siegel and Williams then examined official arrest records for each individual and compared criminal outcomes for the sexually abused group to a matched comparison group who had been seen in the emergency room for other, non–abuse-related incidences (e.g., intestinal illness). They also obtained information regarding juvenile dependency hearings that may have occurred. These dependency hearings reflected official concerns about the suitability of the girl’s home life, including the likelihood of inadequate supervision, absence of care, or overt abuse. As expected, girls who were involved in these dependency hearings were more likely to be arrested later, confirming the expectation that an adverse childhood history predicts offending. However, they also found that sexual abuse as a child was associated with adult offending, even when the adverse childhood (dependency hearing) was statistically controlled. Sexual abuse as a girl was therefore a very potent event in many of these girls’ already troubled lives and an obvious part of their pathway to prison. Adult Victimization The pattern of abuse and victimization experienced as children continues for many incarcerated women into their adult lives. McClellan et al. (1997) surveyed more than 1,000 incarcerated men and 500 incarcerated women regarding their childhood and adulthood maltreatment experiences. Women not only experienced more childhood abuse than did the men, but the abuse was more likely to continue into adulthood. As the men reached adulthood, their rates of victimization decreased, in contrast to the continuing patterns of victimization for the women. Approximately half of the women reported that during their adulthood they were beaten, and nearly one third reported sexual maltreatment or abuse, levels that were beyond those reported by men. In cases of severe physical violence committed against women, the most likely perpetrator was the inmate’s male spouse or partner. In a descriptive study of female offenders in West Virginia, Douglas (2000) found that approximately half reported prior domestic violence committed by a spouse or ex-spouse. Similarly, based on interviews of 195 female inmates, Warren, Loper, and Komarovskaya (2009) reported that approximately half of the sample indicated prior domestic violence. Victimization and Mental Illness The pervasiveness of child and adult victimization among female offenders is a likely precursor to the high levels of mental illness that have been observed in this population. Moreover, the mental illness that women experience as a consequence of such victimization may itself be related to poor patterns of adaptation that can lead to prison. Recently, Salisbury and Van Voorhis (2009) examined how child and adult victimization, among several other variables, contributed to female offending among a sample of 313 female probationers who had committed felony offenses but were not immediately incarcerated. Thus, they were a group at high risk for coming to prison. The purpose of the study was to determine what pathways best described those who ended up in prison. Its results showed the importance of child and adult victimization as key variables in understanding the population. A “childhood victimization model” described an indirect pathway between early mal-treatment and later prison admission among female offenders. In this model, childhood victimization was not directly associated with prison admission. Rather, victimization was associated with a history of mental illness that in turn related to substance abuse and continuing depression and anxiety. In combination, current and previous mental illness and substance abuse paved the road to prison admission. This model supports a notion that early child victimization can “start the ball rolling” for female inmates by leading to mental and emotional distress that directly, or indirectly via substance abuse, increases the likelihood of offending. A second distinct pathway identified by Salisbury and Van Voorhis (2009), termed the “relational model,” included the inmate’s adult victimization experiences. In this model, relational distress, as measured by self-reported involvement in painful, unsatisfying, and unsupportive relationships, was the “starting point” on a path to incarceration. A sense of unhappiness in interpersonal relationships was associated with adult victimization. This experience of victimization during adulthood was related to depression and anxiety that was, in turn, directly related to prison admission. As was the case with childhood victimization, mental illness was also associated with substance abuse, which linked to prison admission. Taken together, both of these models reflect the importance of childhood and adult victimization in the experiences of incarcerated women. The high levels of mental illness found among incarcerated women reflects, in part, these troubled histories of victimization that contribute to offending. Trauma and Mental Illness Childhood and adult victimization are two examples of traumatic experiences that can influence adaptive behavior. A particularly pernicious outcome that can ensue from traumatic experiences is post-traumatic stress disorder (PTSD). This disorder is a consequence of a perceived life-threatening event in which the individual recurrently experiences distress and arousal associated with the event. The individual copes with this turmoil through cognitive and behavioral avoidance such as memory lapse, detachment, flattened affect, and diminished social interaction. PTSD is more frequently observed in women than men, both in incarcerated and nonincarcerated samples (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Tolin & Foa, 2006; Zlotnick, 1997). Warren et al. (2009) examined levels of PTSD and trauma among a sample of 195 female offenders. Consistent with other investigations, they observed high levels of previous violent victimization (74%), previous sexual victimization (61%), and domestic violence (46%), among other possible traumatic experiences. As part of their interview, the women were asked to identify the “worst” of any of the painful experiences they reported and then detail the emotional reactions that ensued. Warren and associates evaluated the women’s reports of their reactions using standardized procedures for diagnosis of PTSD. Approximately half of the sample met criteria for PTSD during their lifetime. Approximately 14% of the women experienced PTSD as a direct consequence of sexual assault. Moreover, diagnosis of PTSD was associated with borderline personality disorder (BPD). BPD represents a long-standing pattern of poor emotional regulation and dysfunctional social relationships and is frequently diagnosed in women in prison (Jordan, Schlenger, Fairbank, & Caddell, 1996). Thus, for many of the interviewed women, their previous traumas continued to play a role in their lives in prison, via associated mental illness and poor emotional regulation. In sum, studies converge on the conclusion that the high levels of victimization and trauma among many female offenders lead either directly or indirectly to mental illness, substance abuse, and chronic patterns of emotional dysregulation. Women who have been victimized can be retraumatized by prison experiences such as pat searches, internal physical searches, privacy violations, and verbal belittlement. If coupled with a disrespectful and devaluating attitude, the power imbalance between prison staff and inmates can evoke prior victimization events, instances which may themselves influence how women are able to cope in prison (Moloney, van den Bergh, & Moller, 2009). Moreover, women who have experienced lifetime sexual assault or domestic violence may be unaccustomed to seeking recourse against such abuse and may be at increased risk of abuse while incarcerated (Human Rights Watch Women’s Rights Project, 1996). Substance Abuse Disorders Among Incarcerated Women Consistent with high risk patterns for mental illness, female offenders suffer high levels of substance abuse problems. Greenfeld and Snell (1999) drew on multiple national surveys of offenders and reported that approximately 40% of the female offenders, in contrast to 32% of the male offenders, were under the influence of drugs at the time of their offense. Approximately one third of the women acknowledged that obtaining money to support their drug habit was the motivation for their criminal acts. Some scholars have argued that the high level of substance abuse found among female offenders represents a form of “self-medication” used to deal with the chronic pain of mental illness (Chesney-Lind, 1997; Sacks, 2004). It is a reasonable conclusion. Among female offenders, there is considerable overlap in the experiences of mental illness and substance abuse. In a study of more than 1,200 jail detainees in Chicago, Abram, Teplin, and McClelland (2003) found that 8% had a co-occurring severe mental disorder, such as schizophrenia or major depression, with substance abuse. Of those with severe mental disorders, nearly 75% met criteria for substance use disorders. Consistent with the pathways to offending models previously described (Salisbury & Van Voorhis, 2009), mental illness and substance abuse interact dynamically with each other in female offenders. Treatment of women in prison requires a lens that includes an understanding of this complexity. Financial, Social, and Familial Problems Among Female Prisoners Financial Hardship Female offenders have numerous financial stressors, often at levels that exceed the high levels of such stress among male offenders. Among parents in prison, more incarcerated mothers than fathers report homelessness prior to prison (Glaze & Maruschak, 2008), and female offenders report higher levels of financial hardship than do male offenders (Heilbrun et al., 2008). Moreover, financial instability appears to be a particularly potent risk factor in the prediction of female offending. Manchak, Skeem, Douglas, and Siranosian (2009) contrasted male and female offenders using the Level of Service Inventory (LSI-R; Andrews & Bonta, 1995), a well-established measure that is frequently used to assess the risk of recidivism. They found that the instrument, composed of 10 separate subscales, did a good job of predicting recidivism for both men and women. However, the particular scales that best accounted for the measure’s predictive power differed. Whereas the best predictors for men were the criminal history scale, financial scale, and alcohol/drug scale, only the financial scale accounted for the measure’s ability to predict the women who would return to prison. The reasons for the potency of financial risk is likely related to its central role in the interplay of adverse circumstances for women offenders. The mental health and substance abuse problems that are frequent in this population can make the women poor candidates for financial stability and good candidates for engaging in activities to finance drug use, for becoming emotionally attached to criminal peers, and for making poor judgment calls (Alemagno, 2001). Parenting Stress Parents in prison, both men and women, routinely report that the separation from children represents one of the most painful aspects of incarceration (Arditti & Few, 2008; Hairston, 1991; Loper, Carlson, Levitt, & Scheffel, 2009; Magaletta & Herbst, 2001). However, the experiences and associated problems can differ. Mothers in prison are more likely than fathers to have been in a single-parent household prior to separation from children (Glaze & Maruschak, 2008). Consequently, children with mothers in prison are much less likely to reside with their other parent (37%) than children with fathers in prison (88.4%). Instead, children of female offenders tend to live with relatives, typically a grandparent. The reverberating consequences for the affected families can be severe. Burton (1992) interviewed 60 grandparents who were rearing the children of drug-addicted parents and documented that many of these seniors’ lives were dramatically changed by the onus of raising their grandchildren. Grandparents expressed concerns regarding their own loss of freedom, their difficulty in keeping up with the emotional and physical demands of parenting, and their questionable ability to handle such a long-term obligation given their own health needs. With an estimated 45% of the children of incarcerated mothers residing with grandparents, the imprisoned mothers have good reason to be concerned about their child’s welfare as well as for their own parents. There are other gender-specific stressors for mothers in prison. Because there are fewer female offenders than male offenders, there are fewer prisons for women. Consequently, there is often a considerable distance between home and prison for a female offender, making it difficult and expensive for her family to visit (Bloom, 1995). There is a greater likelihood of adverse child outcomes among children of incarcerated mothers relative to children of incarcerated fathers (Johnson & Waldfogel, 2002), possibly reflecting the greater disruption in the lives of children of incarcerated mothers. Proportionately more children of incarcerated mothers (11%) in contrast to those of imprisoned fathers (3%) reside in foster care or another equivalent agency, possibly reflecting the greater likelihood of the imprisoned mothers’ single-parent status (Glaze & Maruschak, 2008). The stress associated with inmate mothers’ compromised parental role is linked to symptoms of mental distress and dysfunction that can have implications for women’s adjustment and mental health in prison. In a study of 362 female offenders, Houck and Loper (2002) found that women who reported higher levels of parenting stress regarding their children were more likely to experience symptoms of anxiety and depression. Moreover, stress regarding their children was associated with higher levels of “tickets” or official reports of institutional misconduct. This pattern was largely replicated in a later study with both men and women (Loper et al., 2009), in which parenting stress among the women was associated with heightened depression symptoms as well as increased self-reported violence during incarceration. Based on a series of interviews of mothers recently released on parole, Brown and Bloom (2009) noted that inmate mothers are acutely aware that their children face hardships, mental illness, and dangers that they themselves experienced as children. The frustration that, as prisoners, they were unable to protect their children on a familiar path to prison represented a major source of anxiety for interviewed mothers. The Relevance of Relational Support The importance of relationships within the lives of women has been highlighted by several feminist theorists who emphasize the role of social support and connection for women (e.g., Gilligan, 1982; Lorber, 2001), a theme that is echoed by several scholars who emphasize the importance of social and familial networks for female offenders (Chesney-Lind, 1997; Marcus-Mendoza & Wright, 2004). A recent study (Benda, 2005) provides some support for this gendered emphasis on relationships. Three hundred men and 300 women who had participated in a boot camp program for offenders were followed up for 5 years in an attempt to better understand what makes individuals reoffend. The best predictors for the men were job satisfaction, association with criminal peers, carrying weapons, and aggression during the boot camp experience. These findings are not surprising and are in line with much research concerning criminal prediction of recidivism (Andrews & Bonta, 2006). However, for the women, the predictors of returning to prison included a large number of social and interpersonal features. These included recent sexual and physical maltreatment, living with a criminal partner, depression, and a history of child abuse. Having children and satisfying romantic relationships reduced the probability of return to prison. Although the men likewise showed high levels of disruption on social and relational variables, such adversities were less potent as predictors of a return to prison than was the case for women. This study is consistent with the body of research that attests to the focal role of problematic relationships among female offenders. Illness Consistent with financial hardship, mental illness, and relational distress, disproportionately more female offenders suffer poor health, particularly in terms of infectious diseases, than is the case for male offenders. For example, a recent report indicated that an estimated 12.2% of women in New York state prisons are HIV-positive, a rate that doubles that of male inmates (6.0%; Maruschak, 2006) and is approximately 80 times higher than rates for the general public (Correctional Association of New York, 2009). Along similar lines, levels of hepatitis C infection are proportionately higher among women in correctional settings than among men, with some states reporting infection levels that are as much as double among women (DeGroot, Stubblefield, & Bick, 2001). The pain and potential stigma associated with these diseases can link to feelings of isolation and depression. Interventions that help inmates learn how to deal with their disease appear to be beneficial not only in imparting health information, but also in improving emotional well-being (Pomeroy, Kiam, & Abel, 1999).
Mentally Ill Women in Prison: What Can Be Done? “Why do so many female offenders suffer from mental illness?” can be answered by the consistent body of scholarship that converges on the conclusion that a large portion of this population has experienced traumatic histories, patterns of victimization, substance abuse, and numerous financial and social problems. This leads to the next question: “What can be done?” Based on an assumption that many women come to understand their world in a context that emphasizes relationships and affiliations with loved ones, it is a reasonable leap to assume that optimal treatment takes place within a relational framework and emphasizes the importance of social support to address trauma histories, substance abuse, and parenting issues (Covington & Bloom, 2006; Morash, Bynum, & Koons, 1998; Sorbello, Eccleston, Ward, & Jones, 2002). Although there are, to date, few clinical trials regarding treatments for female offenders (Haywood, Kravitz, Goldman, & Freeman, 2000; Lewis, 2006), there is emerging evidence in support of this premise. There are promising nascent interventions that directly target offenders’ histories of victimization, as well as an emerging body of treatments that focus on the social, familial, and relational stressors that so many female offenders face. Mental Health Treatments Focused on Trauma and Victimization Dialectical Behavior Therapy Linehan (1993) conceptualized BPD as a long-standing pattern of emotional dysregulation caused, in part, by highly aversive early experiences that invalidate the individual’s basic sense of safety. The high levels of BPD among female offenders may be mediated by the early victimization that is so prevalent among this population. Accordingly, Linehan’s well-established treatment for BPD in outpatient samples, termed Dialectical Behavior Therapy (DBT), has been utilized in prisons in multiple countries (Nee & Farman, 2005). DBT is a skills-based cognitive behavioral program that focuses on self-regulation and coping. Individuals are taught to accept and validate themselves and their situation while simultaneously understanding the need for and becoming comfortable with change (Eccleston & Sorbello, 2002). The first stage of DBT involves individual therapy and group-skills training sessions focused on increasing behavioral control. These group sessions involve four modules: Core Mindfulness, Distress Tolerance, Emotional Regulation, and Interpersonal Effectiveness. Subsequent stages focus on post-traumatic stress, self-esteem, and the individual’s personal treatment goals (Nee & Farman, 2005). Nee and Farman (2005) launched a pilot DBT program for 14 women diagnosed with BPD in three British prisons. All of the participants were White women convicted of serious offenses. Results revealed statistically significant improvement on the Borderline Syndrome Index (a global measure of BPD features), as well as on the measures of impulsivity, locus of control, and emotion regulation. However, the use of DBT with women prisoners has its critics. For example, Kendall and Pollack (2003) argue that, when applied in a prison environment, cognitive-behavioral approaches like DBT tend to assume that offenders have failed to develop particular cognitive skills and are characterized by thinking deficits. They point out that these cognitive-behavioral approaches are typically designed by White, middle-class researchers and may discredit legitimate prisoner protests against an oppressive institutional regime. Moreover, Kendall and Pollack question the appropriateness of asking prisoners to discuss very personal and distressing life events in a less than private setting, particularly when they are not guaranteed confidentiality. They point to consent forms that indicate that group facilitators must report significant information about the participant’s past or present criminal behavior disclosed in treatment. Instead, the authors suggest feminist treatment approaches (e.g., Warner, 2001) and argue that inmates should be permitted to utilize community mental health services. Furthermore, Pollack (2005) questions the very label of BPD when applied to disenfranchised inmates. She argues that behaviors such as angry outbursts, substance abuse, self-injury, and dissociation that may earn a woman the BPD diagnosis should be assessed in the context of systemic inequalities (poverty, racism). The behaviors may be regarded as self-protective measures for women who have been traumatized, then retraumatized by a prison environment in which abusive dynamics are replicated. She argues that correctional mental health policy “should not define the consequences of gender, class and racial discrimination as mental health needs” (p. 83) and that characterizations of female inmates as irrational, emotional, angry, needy, and sick should thus be challenged. The Therapeutic Community As is the case with DBT, therapeutic communities (TCs) are increasingly being adopted in correctional settings (Eliason, 2006; Messina & Prendergast, 2001) and represent another intervention aimed at addressing the negative outcomes of trauma, addiction, and associated emotional and behavioral dysregulation. These communities are highly structured treatment programs intended to provide containment, facilitate communication and attachment formation, and involve and empower participants in the community. TCs address mental health issues including trauma, antisocial personality traits, and psychopathy, as well as substance use and vocational needs (Lewis, 2006). The aim is to develop close-knit, prosocial, supportive groups by using a social learning model. Participants are isolated from the prison’s general population. Through peer-counseling they confront and provide feedback to one another in a constructive manner in an effort towards “mutual self-help.” Typical TCs include morning and evening meetings, a system of verbal and written notifications of negative behaviors (“pull-ups”) and positive acknowledgements (“push-ups”), and a sense of community responsibility for upholding morals and values that are conducive to recovery (Pan, Scarpitti, Inciardi, & Lockwood, 1993). A few evaluations of TCs in women’s prisons indicate that they have resulted in reduced recidivism, but studies of the communities’ overall effectiveness are mixed and still uncertain (Messina & Prendergast, 2001). In one of the few studies to examine mental health effects of TCs, Sacks and colleagues (2008) randomly assigned 314 traumatized women to a TC. Alternately, 151 inmates received the standard outpatient program used at the institution, which involved a 90-hour, 15-week, cognitive-behavioral recovery and relapse-prevention course, as well as access to a number of prison offerings (e.g., a trauma-reduction class, adult education, a community reintegration program) and to psychopharmacological treatment. The TC in Sacks and colleagues’ (2008) study, called “Challenge to Change,” involved individual and group counseling and addressed participants’ mental health, trauma and abuse histories, relationships, parenting, substance abuse, criminal behaviors, education, and employment. Interventions were provided for 4 hours each day, 5 days per week; inmates spent the remaining 4 hours per day working within the prison. Peer-led groups and other activities took place on weekends. To make the community sensitive to women’s unique needs, counselors focused on mutual respect, trust, affiliation, leadership, and becoming a positive role model. Efforts were made to avoid authoritarianism and the repetition of past abusive relationships. Participants remained in the TC for an average of 6 and one-half months. Consistent with the study expectations, Sacks and colleagues found that the TC group reported significantly greater reduction of depressive and post-traumatic symptoms 6 months after being released from prison compared to the control group, and both groups reported significant decreases in substance use. However, like DBT, TCs have been criticized as being potentially harmful to inmates. Not only is the little research on their effectiveness mixed (Messina & Prendergast, 2001), but some argue that such communities are better suited to male offenders, who are much more likely to have antisocial personality disorder, than to female offenders, who are more likely to have borderline personality, mood, and/or anxiety disorders. Eliason (2006) argues that the confrontational nature of TCs may provide needed structure and boundaries for men but contribute to feelings of helplessness and trigger PTSD symptoms in depressed women. She argues that women, who are socialized to communicate indirectly, may take this direct communication and criticism as a devastating insult to their self-worth, particularly when it is presented in the very public setting of the community. Eliason also suggests that TCs present relational issues for women by instructing them to be open and vulnerable in the community but also telling them to resist forming strong bonds with individual peers. Finally, according to Eliason, notifications of negative behavior (or “pull-ups”) can be misused to retaliate or threaten women who have no option of presenting their side. Women Helping Women Turn Abuse Around (Esuba) Both DBT and TC represent intensive treatments for female inmates. The criticisms raised by Eliason (2006) and Kendall and Pollack (2003) point to potential dangers in the implementation of the programs in a setting that is, by definition, punitive. Without careful implementation and sensitivity to the conundrum of providing relational support in the context of a punitive environment, the programs may be particularly susceptible to being skewed away from the original intent. Esuba is an alternate program, also directed toward abuse and victimization. However, as a psychoeducational group treatment, rather than an intensive milieu treatment, it may be less prone to the problems identified by critics of DBT and TC. Esuba was developed for incarcerated women with histories of abuse (Bedard, Pate, & Roe-Sepowitz, 2003). It is a psychoeducational therapy group that follows Herman’s (1992) stages of trauma recovery model by providing an emotionally and physically safe environment, remembrance and mourning for past experiences, and finally reconnection or movement toward the future (Ward & Roe-Sepowitz, 2009). It is designed to educate participants about childhood abuse and interpersonal violence, encourage discussion of past experiences, and teach anger management and communication skills (Bedard et al., 2003). Importantly, Esuba emphasizes relationships between participants and the importance of social support while attempting to decrease isolation, shame, and fear (Ward & Roe-Sepowitz, 2009). Ward and Roe-Sepowitz (2009) documented positive effects of Esuba in an evaluation of a 12-week program for 18 women (who self-identified as having prostituted themselves) in a moderate-security southern prison. Consistent with patterns for most female offenders, the majority of the women had experienced significant childhood and domestic abuse, had substantial substance abuse problems, and had a high level of depression and suicidal episodes. Preassessments and postassessments revealed significant reductions of trauma-related symptoms (e.g., dissociation, nightmares, flashback), as well as reductions in anxiety and depression. Participants also reported improved self-awareness and self-confidence. Bedard et al. (2003) likewise documented positive effects for Esuba in a study of the effect of a two-phase, 24-week program on the self-esteem of traumatized inmates (96 females and 61 males). Results indicated that the Esuba program significantly improved offenders’ mean self-esteem scores. Furthermore, female inmates reported decreased sensitivity to criticism and increased trust in others, stability of self, and self-satisfaction. Summary: Trauma-Focused Intervention Given the high levels of trauma and victimization among female offenders, and the pathways between such trauma and offending, it is sensible to position treatment within a context for dealing with grief and anger stemming from past victimization. For women with long-standing problems with associated emotional dysregulation, intensive treatments such as DBT or TC make sense. The rationale and theoretical assumptions that focus on the importance of relationships, healing, and intensive support likewise are reasonable. However, if implemented improperly, these treatments may cause more harm than good. The less intensive treatments, such as Esuba, may be less prone to these problems but are plausibly less effective with highly traumatized inmates. This is a clear area where more clinical trials are needed to document both positive and negative outcomes of trauma-focused treatments and to determine whether and for whom “high-dosage” treatments, such as DBT and TC, are appropriate. Interventions That Indirectly Address the Mental Health Needs of Female Offenders The negative effects of victimization and abuse (i.e., mental illness, substance abuse, and emotional dysregulation) are the targets of several previously described trauma-focused interventions. Often the women in these interventions have substantial and well-documented mental illness that captures the attention of the correctional institution. However, many women in prison may suffer from depression and anxiety that can become “normalized” in a context where there are so many women with clear evidence of mental distress. For many women in prison, their most likely form of mental health intervention may come not so much from a designated mental health intervention, but from an intervention designed to treat or ameliorate other stressors. For example, most women’s prisons have parenting classes for inmates (Pollock, 2002) that can serve to indirectly improve the stress among the affected mothers (Loper & Turek, 2006). Interventions that address prominent stressors for incarcerated women, such as separation from children, physical illness, and lack of relational support, can provide mental health benefits in the correctional setting. Parenting Programs Loper and Novero (in press) reviewed 23 parenting education interventions for incarcerated parents. Although the interventions differed in length and content, they shared a focus on improving communication patterns between inmate parents and their children within the context of a prison separation. Most of the interventions measured outcomes in terms of parenting attitudes and communication patterns with children and care-givers. However, 10 of the interventions also included measures of emotional well-being, such as self-esteem, parenting stress, and mental health symptoms. In 9 of these 10 studies, there were reported beneficial effects. For example, Loper and Turek (in press) evaluated a parenting program designed for mothers in prison that taught inmates a strategy for dealing with parenting stress through brief relaxation to reduce impulsive reactions, followed by cognitive reframing of negative thoughts about themselves and their relationships with children. The intervention taught strategies for having positive connections with children in the viable communications open to long-term offenders (i.e., phone calls, letters, personal visits, and contact with caregivers). In an evaluation of the program with 106 imprisoned mothers, Loper and Turek found significant reductions in parenting stress, depression, anxiety, and other mental health indices. Other studies of parenting interventions likewise point to mental health benefits for the inmates. For example, in a study of women in a state prison, Harm, Thompson, and Chambers (1998) found that inmates with serious drug or alcohol problems, as well as inmates who had reported previous physical abuse, showed significant improvements on measures of self-esteem after participation in a parenting education program. Parenting programs may enhance the mental health of female inmates in other ways. Houck and Loper (2002) found that women with higher levels of parenting distress also had more “tickets” or official documentation of infractions at the prison. If parenting programs are successful in reducing incarcerated mothers’ parenting stress, and associated feelings of emotional turmoil, these women may be more able to be good citizens of the institution and better adjust to the constraints of prison life. Parenting programs may also offer an opportunity for connection and community with other offenders that can likewise serve to heal. For example, in Virginia, Mothers Inside Loving Kids (MILK) continues to operate as a community of incarcerated women who meet weekly to discuss difficulties and stressors related to being a mother in prison, plan activities for upcoming visits, and receive educational information regarding parenting (Moore & Clement, 1998). Community Engagement Through Religious Activities The sense of community and personal support that can be important to the mental health of female inmates is not always easily available in prisons. Depending upon the security level of the institution, the formation of community may be overtly discouraged to ensure safety. Although education programs, such as parenting classes, may offer such a community, inmates often have to wait a long time to enroll in these activities, which are usually time-limited. Religious participation, though not a mental health intervention in itself, can enable the creation of a community for offenders that is reliably offered and accessible. The Religious Land Use Act and Institutionalized Persons Act of 2000 protects prisoners’ right to exercise their religion. Like other prosocial educational opportunities, it has been shown to have positive effects on inmates’ mental health. O’Connor, Ryan, Sakovich, and Parikh (1997) surveyed 23 inmates who recently attended Prison Fellowship Bible study sessions in a maximum-security women’s prison in South Carolina. The women stated that religious programs were more helpful than their family, friends, work, education, and psychiatric programs for adjustment to prison life. Similarly, during interviews with 35 female inmates in a medium-security prison in the Midwest, Greer (2002) found that religious experiences reportedly helped 16 of the women address the emotional discord they felt while in prison. Several women stated that their belief in a “higher power” helped them cope with their traumatic past, their volatile emotions (which they had previously suppressed with drugs), and the uncertainty of their future. During a focus group with 15 African American mothers in a midwestern prison, many of the women reported depending on their spirituality to make sense of their imprisonment and provide hope for the future (Stringer, 2009). Finally, in a study of 213 women incarcerated in central Virginia, Levitt and Loper (2009) found that women who reported receiving a high degree of support from their participation in religious activities reported less depression and fewer instances of feeling angry than those who did not attend religious activities. Religious activities, like parenting programs or healthcare educational programs, are not designed specifically as mental health interventions. However, the reported improvements in emotional well-being of women involved in such programming fits with the findings about the key ingredient of successful mental health intervention: a supportive network that provides an opportunity to safely process previous traumas and learn prosocial behaviors. Prison Animal Programs An unconventional, but potentially effective, mental health intervention is a prison animal program. Such programs are increasingly being incorporated into correctional offerings (Furst, 2006). Prison animal programs operate in at least 36 U.S. states, Canada, Australia, New Zealand, and Italy, and most commonly follow a community service model in which homeless animals (usually dogs) at risk for euthanasia are trained by inmates so that they are more adoptable and then returned to the shelter. In other programs, inmates train service dogs for disabled people. Although animals are not necessarily included as a therapeutic intervention for the inmate or used in conjunction with clinical methods, anecdotal reports typically reflect the value of these programs on prisoners’ mental health (Furst, 2006). For example, in a study at a maximum-security psychiatric hospital for the criminally insane, patients on a ward with pets required “half as much medication, had drastically reduced incidents of violence, and had no suicide attempts during the year-long comparison period” (Lee, 1987, p. 232, as cited in Furst, 2006). By contrast, the ward without pets had eight documented suicide attempts during the same year. The therapeutic value of the animals seems to result from several factors, among them the sometimes tumultuous relationships inmates have with one another and their limited opportunities to develop relationships with noninmates. Animals provide unconditional positive regard. They do not care about the inmates’ past mistakes. They also provide a sense of security, an outlet for physical affection (Furst, 2006), and fulfillment of an individual’s need to nurture. Animal programs sometimes include vocational training and/or employment for prisoners as well (Walsh & Mertin, 1994). Although the theorized mental health benefits of animal programs make sense, to date there are few studies that systematically evaluate the benefits of such intervention. A welcome exception is a recent study of dog training programs at a women’s prison in Kansas. Britton and Button (2007) reported that many women found the routines and schedules that caring for an animal imposed to be useful because it forced them to get out of bed and tend to the dogs despite their depression. Importantly, caring for abused animals provided a unique way for the women, many of whom had also been abused, to work through their own trauma issues by identifying with the animal’s own difficult past. Both inmates and staff reported that the presence of the dogs seemed to have a “normalizing” effect on the prison, making it seem like a calmer, less sterile environment. The dogs’ presence improved relationships between staff members and inmates by providing a neutral context for interactions in which normally authoritarian staff might soften. Furthermore, training dogs was one of the only opportunities for meaningful work offered by the prison, which tended to employ inmates in institutional maintenance. The graduation ceremonies, in which trained dogs were given to recipients who expressed nonjudgmental gratitude, were particularly emotional for the inmates; the authors noted the necessity of receiving this kind of feedback for women. One inmate reflected on the parallel between her own lack of freedom and the freedom provided to the disabled individuals who would be given the service dogs she trained: “We’re locked up inside a fence, those people are locked up in their own bodies. I am glad that I can give them some freedom to live” (p. 206). Case History Consider the case of Sue Kennon, a 59-year-old woman who spent 15 years behind bars at the Virginia Correctional Center for Women in Goochland, Virginia (see Text Box 10.1). Like many female inmates, Sue experienced trauma and struggled with drug addiction prior to entering prison. In an interview with the authors, Sue describes her pathway to prison, as well as her efforts to overcome sadness and to find meaning during her years in prison. TEXT BOX 10.1 SUE’S STORY 1. Tell us about your life before coming to prison. I came from a nice home, and I moved to Richmond, Virginia, where I met my husband, C. He was beautiful to look at, funny, got a little crazy streak. We were married for 2 years when I became pregnant. Life was good. And then the stress happened. It was July—real hot days. He went to the boat landing to go for a swim and cool off. I got a call from one of the neighbors down there and they wanted me to come because he was hurt. I was 7 months pregnant. I went to the dock and I saw an ambulance. I jumped in the ambulance and there he was. Not a scratch on him. Didn’t look dead. He had hit a submerged log and severed his spinal chord. That was the big stressor. 2. So what did you do next? C was a disabled vet and he would get these severe migraine headaches and take some painkiller. I started taking them. I started going to all these doctors in Richmond [for prescriptions] and I started hanging out at the cemetery all the time, thinking of C. At that point, I had been to about 50,000 doctors, for prescriptions. But you rationalize it because you are taking a prescription and it was legal. After 3 years, I ran into a guy I went to high school with and I started living with him. We had two little boys together. So, now I had three children and I was scared because I knew I was going to get caught. I tried to detox myself. But you cannot do that alone. I ran into a girl I knew from school. I told her I was calling in scripts and I was scared to death of getting caught, and she explained to me it was easy to get heroin. So I did. 3. How did you pay for the drugs? I stole from everybody, my mother and father, my children’s piggy banks, stores. Pawn shops all knew me. I pawned everything I had. I loaned my car out to the dope man for a weekend. It didn’t even take 6 months before getting a big habit. All I wanted to do was feel good on my own without this wrenching, awful pain about C. I did not go to a psychologist or a psychiatrist. It was a family thing. We do not let anybody see our emotions kind of thing. 4. How were you arrested? I decided, okay, you are going to have to end it [her life]. In the meantime, I am going through withdrawal. I went to the shopping center, got a little toy gun, and robbed three little dress shops. I was a stupid robber. On all three robberies I got only $180 total. Then after that came the day. It was a beautiful July Saturday, and I knew that I could not wait to die. The gut-wrenching part was trying to figure out how to say goodbye to my children. So I decided when they were taking their naps I would write each of them a little letter trying to explain as best I could that it was nothing they did, that Mommy was sick and they could forgive me. So I did that. There was a guy in the neighborhood who repaired old guns and so I went to visit his wife. When she stepped out of the room for a minute, I pulled a gun down and put it in my pocketbook—no bullets, though. Then I went to this pharmacy with it. I pulled the gun out, said I was an addict and wanted to die, and just “give me all of your narcotics.” It all happened so fast. He rushed toward me and I heard this noise, and I start running out the door. I remember feeling that I was wet and like I was on an escalator. For a minute I thought I was dead, and then I thought, “Well, I am wet, maybe he threw a pail of water on me.” I look over and my arm is hanging off of me, blood everywhere. I had been shot and I didn’t even feel it. So I did a 180 and ran back at him, put my hands up and cried and begged him to put a bullet in my head before the police came. I said “I can’t live like this anymore, please don’t make me live like this anymore.” 5. What was it like when you were arrested? I walked into the jail. I was looking all crazy and I had my arm in a sling. All I could do was cry. Turns out the women there were like a sisterhood, and they just wanted to help out another addict. For 6 days they took care of me. It was nasty and gross, and horrible and painful. When I finally got to my own mind and realized how I had failed, the only thing that came to my head was something my grandmother used to say, “If you ever feel like you just can’t draw another breath, just go tell the truth and shame the devil.” So, I had a court appointed lawyer and I told him, “Let’s just say that I am guilty.” I ended up with 48 years. When I got up here to the prison, I found out that I did not have parole. [Under an interpretation of the Virginia “three-strikes” law, Sue was considered a repeat offender as she confessed to multiple robberies, and she received the maximum sentence with no parole.] 6. What was the hardest part of prison? Being separated from my children was the worst thing. The sickness that stays with you in your heart and your stomach, knowing that one day they are going to want to talk to you about this, and why do they have to see Mommy by going up to this prison. They were just too little to understand. That was the worst pain that I have ever felt in my life. I’d look at pictures and then go through and look at pictures again. And then some days I couldn’t look—too hard. And hearing these little voices. You miss everything—every graduation, proms, first dates, events. Oh God! The guilt will just eat you alive if you are not careful. 7. Did you ever get mental health treatment in prison? I had a counselor. She was the most kind, understanding, and supportive person I have ever met in my life. We found these crazy hats one day–all kinds of ladies hats with the little veil that goes over your nose. We put them on and laughed, like we were at a tea or something. It felt so human and fun. In year 12 [of her sentence], I remember clear as a bell waking up that day thinking, “I have only done 12 years of this sentence—just a part. I have so many more.” I lost my appetite, became lethargic, dark circles under my eyes, because I couldn’t sleep. I dumped off weight. Finally, I sent a message to Dr. T, our psychiatrist. She got me in real quick, and things got better. 8. What made the biggest difference in your mental health and adjustment in prison? Well, education. This wonderful little old woman met the chaplain from the prison and she wrote to me and she asked what she could do to help me want to live. I only had a high school degree, and I thought maybe she can help me with a long-distance learning course, Psych 101. That’s how this started. [Sue continued her online education and went on to receive her AA degree, and then a BA from Ohio University. She became the first offender in Virginia to receive a BA degree while incarcerated. After release, she completed work initiated during prison on a master’s degree in developmental psychology from Virginia Commonwealth University.] Also the women I knew in prison made a difference. When my daughter got married, I wanted to get her something real personal. The lady in the gym gave me some beautiful blue satin, lace, and elastic. I brought it back and called everybody, “Let’s do the garter thing for my daughter.” Oh, they made the most beautiful garter. She still has it to this day. I put it in a box and sent it to her with this poem that my sister-in-law read at the shower. Then I wrote the assistant warden to see if a family member could make a video and send it to me. She worked it out so I could. Then the whole rec room, they fixed a big thing of popcorn and we all watched my daughter. We are jumping up and crying. When we heard “You may kiss the bride,” everybody started throwing popcorn and singing. It was just wonderful. The next day my daughter and her new husband, instead of going on their honeymoon, came to see me. So much to be grateful for. A lot of pain and a lot of good stuff. 9. Your master’s thesis was on the parenting education program you developed? Yes. I am really interested in child development, what’s going on with kids, so I focused my studies on that. I looked for a parenting program for mothers in prison, but there was none. So that’s when I got the idea to write my own. It took a couple years trying different things out in classes I taught with the women, and once it was done, the DCE [Virginia Department of Correctional Education] accepted it and thought it was really good and made it part of the curriculum. During Sue’s 15th year, there was growing pressure from numerous individuals inside and outside of the correctional system to reevaluate the appropriateness of the “three-strikes” law for Sue’s sentencing. Based on her achievements in prison, she was subsequently not only granted parole but was shortly thereafter hired by the DCE as coordinator of parenting education. The parenting curriculum she developed in prison is in use today by Virginia inmates (Virginia Department of Correctional Education, 2007). In 2006, the governor of Virginia presented Suzanne Kennon with a special award in recognition of her innovative programming and contribution to correctional education. While on the stage to receive her award, she reports that Governor Kaine leaned over and quietly asked, “Did you ever imagine you would be here?” Like the majority of female offenders, Sue’s pathway to prison involved an initial traumatic event—the sudden loss of her husband. She medicated her depression and pain with prescription drugs and eventually heroin. She stole to obtain money to buy drugs. Her offense was itself a suicide attempt. Once in prison, her greatest anguish was separation from her beloved children. These are experiences she shares with many of the women in prison today. Unlike many women in prison, Sue’s story has a happy ending. The relationship she formed with her counselor, her community with other offenders, and most of all, the opportunity to pursue an education and then offer the benefits of that education to other inmates led Sue to her current success. Other women in prison who suffer from mental distress can likewise find relief through interventions that provide a safe and supportive environment, the chance to deal with emotional pain, and educational programs that teach new skills and engender a sense of self-worth. Summary and Conclusions More research is needed regarding the effectiveness of interventions for female offenders. With some exceptions, there are few intervention studies that include stringent benchmarks for learning what works, such as random assignment to treatments, inclusion of control groups, adequate sample size, and attention to measuring treatment integrity. But the theoretical basis for designing gender-specific and effective intervention is available, drawing from the mounting body of research attesting to the intersection of mental illness with previous victimization and trauma, substance abuse, and numerous social and familial stressors, as well as the importance of supportive relationships and community. The road from theory to practice for treating mental illness in female offenders still needs some paving. But the groundwork is strong, the need is clear, and more and better interventions are emerging. KEY TERMS Prevalence rates Victimization Physical and sexual abuse Domestic violence Substance abuse Mental illness Childhood Victimization Model Relational Model Trauma Post-traumatic stress disorder (PTSD) Borderline personality disorder (BPD) Emotional dysregulation Self-medication Co-occurring mental disorders Parenting stress Social support Dialectic Behavior Therapy (DBT) Therapeutic community Trauma-focused interventions Parenting programs Community engagement programs Prison animal programs DISCUSSION QUESTIONS How is the prison experience different for male and female offenders? Are there different issues or factors that influence or impact prison adjustment for male and female offenders? Describe two common pathways that lead women to prison. What are the obstacles, ethical concerns, benefits, or drawbacks to importing therapy programs that have been demonstrated to be effective in the community into the prison environment? 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