CGRreIeMn Eet &al .D / ENLEIENDQSU OEFN CWYO /M JAENNU IANR JYA I2L005 10.1177/0011128704267477 Trauma Exposure, Mental Health Functioning, and Program Needs of Women in Jail Bonnie L. Green Jeanne Miranda Anahita Daroowalla Juned Siddique Aconveniencesampleof100femalejailinmateswasinterviewedbytwofemaleclinical psychologistsusingmeasuresoftraumaexposure,psychopathology,sexualriskbehav- ior,parentingskills,andperceivedneedsforservice.Participantshadhighratesoflife- timetraumaexposure(98%),currentmentaldisorders(36%),anddrug/alcoholprob- lems(74%).Morethanhalfofthewomenshoweddeficitsinparentingskills.Participants describedtheirprimaryproblemsasbeingintheareasofsubstanceabuseandfamily issues,andtheyendorsedavarietyofpotentialservicestheywouldliketobeableto access.Unlesstraumaandvictimizationexperiences,mentalhealthneeds,andfunc- tionaldifficultiesaretakenintoaccountinprogramdevelopment,incarceratedwomen are unlikely to benefit optimally from in-house and postrelease programs. Keywords: incarceratedwomen;jaildetainees;interpersonaltrauma;mentalhealth; substance abuse; parenting; programming needs TheBureauofJusticerecentlyreportedthatthenation’sjailpopulation hasincreasedmorethan40%since1990(U.S.DepartmentofJustice,2003) withratesofincarcerationincreasingmoreforwomenthanformen.Since 1995,themalepopulationhasrisenby3.8%annually,whereasthefemale populationhasrisenby5.9%.Thisdramaticgrowthhasbeenattributedto increasesinillicitdruguseamongwomenalongwithanincreaseindrug- related convictions and mandatory sentencing (Covington, 1998; Owen & Bloom,1995;U.S.DepartmentofJustice,1999).Evenso,womeninmates stillmakeuponly12%ofthejailpopulation(U.S.DepartmentofJustice, 2003).Perhapsforthisreason,relativelylittleattentionhasbeenpaidtothe BONNIE L. GREEN: Department of Psychiatry, Georgetown University Medical Center. JEANNE MIRANDA: University of California—Los Angeles Neuropsychiatric Institute, CenterforHealthServicesResearch.ANAHITADAROOWALLA:TheKingsburyCenter, Washington,DC.JUNEDSIDDIQUE:UniversityofCalifornia—LosAngelesNeuropsychiat- ric Institute, Center for Health Services Research. CRIME & DELINQUENCY, Volume 51 Number 1 January 2005 133-151 DOI:10.1177/0011128704267477 © 2005 Sage Publications 133 134 CRIME & DELINQUENCY / JANUARY 2005 needs of this small but growing population (Koons, Burrow, Morash, & Bynum, 1997). Mostincarceratedwomenaremothers;7in10womenundercorrectional sanction have minor children (U.S. Department of Justice, 1999). Several studies have examined the impact on children of their mother’s incarcera- tion,andtheeffectsarequitenegative:Thesechildrensufferemotionaldis- tress,poorschoolperformance,andaggressivebehavior(Greene,Haney,& Hurtado, 2000). Yet little is known about the capabilities of incarcerated womentofulfilltheirparentingrolesoncetheyarereleasedfromprisonor thevulnerabilitiesoftheirchildrenbasedonpreviousinteractionswiththese mothers. Womenprisonershavealsobeenshowntohaveveryhighexposuretoa varietyoftraumaexperiences,especiallytointerpersonalviolence,including childhoodphysicalandsexualabuse(Battle,Zlotnick,Najavits,Gutierrez,& Winsor,2003;Browne,Miller,&Maguin,1999;Greeneetal.,2000;Jordan, Schlenger, Fairbank, & Caddell, 1996; Owen & Bloom, 1995; Teplin, Abram,&McClelland,1996).Theyalsohavehighratesofmentaldisorders and substance abuse (Battle et al., 2003; Jordan et al., 1996; Sanders, McNeill,Rienzi,&DeLouth,1997;Teplinetal.,1996).Forexample,ina studyof1,272femalearresteesawaitingtrialattheCookCountyDepartment ofCorrectionsinChicago(Teplinetal.,1996),60%ofthesamplehadasub- stanceabusediagnosis,14%metcriteriaforcurrentmajordepression,and 22%metcriteriaforcurrentpost-traumaticstressdisorder(PTSD).Arecent reviewsuggeststhatexposuretotraumaticeventsisnearlyuniversalamong incarceratedwomenwithstudiesshowingrangesoftraumaexposuretobe between77%and90%(Battleetal.,2003),includingarangeofestimatesfor eachtypeof trauma,butwithallrateswellexceeding thoseinthegeneral population (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Indeed, theexperienceoftraumaislikelyadeterminingfactorintheinvolvementin criminalbehaviorforwomenthroughsuchmechanismsaschildabuselead- ing to early running away and abuse-related psychopathology like PTSD leadingtosubstanceabuseforself-medicationpurposes,both,inturn,being associated with increased risk for criminal behavior (Battle et al., 2003). ThisworkwasfundedbyPrinceGeorge’sCounty,Maryland,HealthDepartment.Wewouldlike tothankElishaFriedmanforherhelpinterviewingthewomeninthisstudy.Weacknowledge MeganMurphyandCarolinedeBenedictusfortheirhelpwithdatacodingandMaryAnnDutton, LisaJaycox,andStaceyKaltmanfortheircommentsonearlierversionsofthemanuscript.We thankDellaDonaldsonandWillieNelsonfortheirhelpinfacilitatingsmoothcollectionofdata withinthejailandforprovidingdataonwomeninmates.Weappreciatetheoversightandguid- anceofArtThatcher,JoanGleckel,andRobertCulleninconceivingofandremainingcommitted tothisinnovativeandimportantareaofinvestigation.Finally,wethankthewomenwhopartici- pated in this project for their willingness to share many aspects of their lives with us. Green et al. / NEEDS OF WOMEN IN JAIL 135 Trauma exposure, especially interpersonal trauma, is also a significant predictorofriskyhealthbehaviorsincludingsmoking,substanceabuse,and risky sexual behavior (Rheingold, Acierno, & Resnick, 2004). HIV risk behaviorswereexaminedinarecentstudyofwomenprisoners(Huttonetal., 2001);56%ofthewomenneverorrarelyusedcondoms,and7%had100or morelifetimesexualpartners.Otherriskbehaviorswerehighaswell,includ- ingneedlesharing,receptiveanalintercourse,andbeinghighduringinter- course.PTSDwasindependentlyassociatedwiththepracticeofanalsexand prostitution, another health risk behavior. Historically,jailserviceshavebeendevelopedfor,andaremostlygeared toward,maleinmates.However,recentstudiessuggestthattheneedforser- vicestargetingwomenandtheirspecificissuesareincreasinglyrecognized. For example,Koons etal.(1997) didacomprehensivesurveyof stateand federaladministratorsinsettingswherewomenwereincarceratedtoexam- inetreatmentprogramsinplaceintheirownjurisdictions.Theareascovered by these programs included substance abuse education (55%), substance abusetreatment(47%),programsforparenting(44%),lifeskills(42%),and relationshipskills(37%).Programsaddressingotherareaswereavailablein lessthanonequarterofthesurveyedsites,withprograms targetingsexual abusebeingidentifiedbyonly13%ofprogramsandmentalhealthbeingtar- geted by only 7% of participants. Administrators indicated that their pro- gramstendedtotargetfiveormoreareas.Indeed,inspiteofvariousman- datestoprovideatleastbasicmentalhealthtreatmentinthecriminaljustice system, only a minority of jails offers a comprehensive range of services (Steadman,Barbera,&Dennis,1994).Inamoregeneralsurveyofmental healthservicesinjailsservingbothmenandwomen,Morris,Steadman,and Veysey(1997)foundthatalthough50%ofthejailstheysurveyedprovided crisisinterventionandpsychotropicmedications,otherservicesweremuch less common. Only about a third of the sitesoffered counseling, and only aboutaquarterreportedofferingdischargeplanning—clearlyacriticalele- ment in a plan to prevent recidivism. Although services targeting women and acknowledging their gender- specific victimization experiences are becoming more common (Welle, Falkin,&Jainchill,1998)andavarietyofnewlydevelopedservicestargeted at women inmates’particular needs have been proposed (e.g., Covington, 1998; Zlotnick, Najavits, Rohsenow, & Johnson, 2003), these specialized servicescontinuetobetheexceptionratherthantherule.Furthermore,data available to inform creation of appropriate and effective gender-specific services are still quite limited (Battle et al., 2003; Greene et al., 2000; Sanders et al., 1997; Welle et al., 1998). Experts generally agree that the goalsofinterventionandrehabilitationprogramsforincarceratedindividu- 136 CRIME & DELINQUENCY / JANUARY 2005 alsareeconomicandsocialindependence,familyreunification,andreduced involvementincriminalactivities(Koonsetal.,1997).However,muchisstill tobelearnedabouttheneedsofwomenprisoners—informationthatcould informwhattypesofprogramsmightbeacceptedandeffectiveinaddressing these goals. Inthisstudy,weexaminedtraumaexposure,mentalhealthproblems,and substanceabuseissuesamongasampleoffemalejaildetaineesinacounty facility.Eachareahasstrongimplicationsforthedevelopmentofappropriate services.Wealsoexpandedthefocusbeyondthesepreviouslystudiedvari- ablestoincludeseveralotherareasthathaveimportantimplicationsforthe economic,social,andfamilygoalsdescribedaboveincludingriskysexual behaviorandparentingcapacity.Finally,weinterviewedthewomenabout theirownperceptionsofneedandwhatservicestheywouldfindusefulwhile incarcerated. METHOD Procedures AconveniencesampleoffemaleinmatevolunteersatthePrinceGeorge’s County Correctional Center participated in this project. All participants signed up for the study after hearing a presentation; inmates were not approachedindividually.Thisdesignwasafunctionofdiscussionswithjail administrators and requirements of the State of Maryland Institutional ReviewBoard,whichincludedaprisoneradvocate.Ithonoredtheconcerns ofbothgroupsregardingtheneedforanonymityoftherespondentsinregard toreportingabuseexperiencesaswellastheneedtoavoidanyrealorappar- ent coercion for the women to participate.Approximately 125 women are presentinthisfacilityatagiventime,housedtogetherinonesection,with staysofvaryinglengths.Somewomenarepretrialdetainees,whereasothers areservingsentencesfollowingconviction.BetweenAugust2000andJanu- ary2001,brieforalexplanationsofthestudywerepresentedtowomenresi- dents of the facility. These presentations were made periodically to insure thatnewresidentswereawareofthestudy.Duringthepresentation,women weretoldaboutthenatureofthestudyandthetimerequiredforparticipation. Aquestion-and-answerperiodfollowed.Interestedwomensignedupforan interview at a later date. Before beginning the main interview measures, interviewers reviewed the informed consent procedure in detail with each volunteertoinsurethatsheclearlyunderstoodtheprocedureandthestudy. Green et al. / NEEDS OF WOMEN IN JAIL 137 Participatingwomenweregivena$15certificategoodforpurchasesinthe center store in partial compensation for their time. Theinterviewtookapproximately1.5to2hourstocomplete.Theinter- viewers were two female clinical psychologists (Ph.D.s) with clinical and research interviewing experience. Measures The measures used in the study were selected for a variety of reasons including thewish to keep thetotalamount of timereasonable, theuse of standardized measures when possible, and the use of measures that the researchgroupwasfamiliarwithandthatwehadusedinpreviousstudies, especially studies of low-income, primarily minority women. Trauma exposure. The trauma screening measure from the National ComorbiditySurvey(NCS;Kessleretal.,1995)ofthegeneralpopulationof theUnitedStatesaged15to55wasusedtoassesslifetimehistoryoftrauma. Twelvecategories of trauma were assessed. The 12 standard itemson this instrumentweresupplementedwith4additionalitemsdesignedtoovercome underreportingassociatedwithusingemotionallyladenwordssuchasrape and abuse. In each case, we followed the item containing an emotionally ladenwordwithaseconditemthatdescribedthesameexperiencebehavior- allyandbeganwiththephrase,“Evenifyoudidn’tthinkofitas(event).., someone(behavioraldescription).”Forexample,theitemqueryingpartici- pantsabouthavingbeenrapedwasfollowedbytheitem,“Evenifyoudidnot thinkaboutitasarape,someone(forexample,aparent,caregiver,spouse, romanticpartner,acquaintance,orstranger)forcedyoutohaveoraloranal sexorintercourseagainstyourwillorwhenyouweredruggedorhelpless.” The items on this scale can be summed to measure the number of trauma categories the participant has ever experienced. Substanceabuse.Becausesubstanceabusewasnotaprimaryfocusofthe study, screening measures were used in this area. The Tweak Test (Chan, Pristach,Welte,&Russell,1993)wasusedtoassessprioralcoholabuse.This 5-itemmeasureexaminestoleranceforalcohol,worriesorcomplaintsabout drinking,drinkingduringthemorning,blackouts,andfeelingtheneedtocut downondrinking.Themaximumscoreis7;thosewithascoreof4ormore aredesignatedashavinganalcoholproblem.Drugabusewasassessedwith twosetsofquestionstakenfromtheAlcoholUseDisorderandAssociated Disabilities Interview Schedule—Alcohol/Drug-Revised (Chatterji et al., 138 CRIME & DELINQUENCY / JANUARY 2005 1997). Women were asked if they used any drugs or medicines in the 6 months prior to incarceration. Follow-up questions asked about nine drug categories:(a)sedatives;(b)tranquilizersorantianxietydrugs;(c)painkill- ers;(d)stimulants;(e)marijuana;(f)cocaine,crack,orheroin;(g)hallucino- gens; (h) inhalants or solvents; or (i) any other medicines, drugs, or sub- stances. For the present study, we focused only on illegal drugs, because abuse of other substances was rarely reported. We designated those who reportedusingmarijuana,crack,cocaineorheroin,orhallucinogensasillicit drug users. Psychiatricdisorders.Thisstudyfocusedonmooddisordersandtheanx- iety disorder most strongly associated with trauma exposure—PTSD. The PrimaryCareEvaluationofMentalDisorders (PRIME-MD;Spitzeretal., 1994)usesDiagnosticandStatisticalManualofMentalDisorders(4thed.; DSM-IV;AmericanPsychiatricAssociation,1994)criteriatomeasuremood disordersincludingmajordepressivedisorder(MDD).Itwasusedinalarge depression treatment trial conducted by the investigators and others (Miranda et al., 2003), which recruited primarily low-income, minority women.GoodagreementbetweenthePRIME-MDandindependentpsychi- atric diagnosis (assessed by a modified version of the Structured Clinical InterviewforDSM-IV)hasbeenestablished.Wealsoassesseddysthymia,a chronicdepressiveconditionthatcontinuesfor2yearsormore,andincluded ascreenerquestionaboutbipolardisorder.PTSDwasevaluatedusingamod- uleoftheCompositeInternationalDiagnosticInterview(CIDI;Kessleretal., 1995;WorldHealthOrganization,1997)fromtheNCS,whichfocusesonthe most distressing traumatic event the women report, and asks about PTSD symptoms associated with that event. Sexualandreproductivebehavior.Theseitemsweretakenfromaprevi- ous study of young adult women done by the research team (Green et al., 2004) and included questions about menstrual periods, age at first inter- course,numberoflifetimesexualpartners,useofbirthcontrol,andtestsfor HIV.Thesetypesofquestionsaresimilartootherstudiesofriskysexualand reproductive behavior (e.g., Molitor, Ruiz, Klausner, & McFarland, 2000). Parenting.TheAdult-AdolescentParentingInventory(Bavolek&Keene, 1999)wasusedtoevaluatehowthewomenwerefunctioningasparents.It consistsof40itemswithwhichtheparticipantagreesordisagreesona5- point scale.The itemsaddress general attitudesand beliefs about children and parenting. Subscales measure five specific risk areas: inappropriate Green et al. / NEEDS OF WOMEN IN JAIL 139 expectations of children, lack of empathy toward children’s needs, strong beliefintheuseofcorporalpunishmentasdiscipline,reversingparent-child role responsibilities, and oppressing children’s power and independence. Themeasurehasbeenextensivelynormedamongindividualsparticipating incountyagencyprogramsthroughout23states,andeachofthefivescales discriminatesbetweengroupsofparentsknowntobeabusiveorneglectful and more general groups. Perceived Needs Women were asked an open-ended question about their perceptions of need(“Asidefromincarceration,whatdoyouseeasyourbiggestproblems rightnow?”),andtheirresponsesweregroupedintocategories:drugoralco- holproblems(e.g.,wantingtostayoffdrugs),beingawayfromorworrying about family (e.g., being away from kids), problems with life direction or neededskills(e.g.,gettingmyhealthright,gettingmylifeinorder),needing ajobortraining(e.g.,tryingtogetastablejob),andmiscellaneous.Catego- riesweremutuallyexclusive.Theywerealsogivenalistofpotentialtypesof programs(e.g.,drugeducation,GeneralEquivalencyDiploma[GED]prepa- ration, job training, anger management, parenting skills) and asked which theywouldliketohaveavailabletotheminjail,andtheywereinvitedtosug- gest additional areas for programming. RESULTS Sample Onehundredwomenparticipatedinthisproject.Thedemographicchar- acteristicsofthesamplearepresentedinTable1.Ascanbeseen,thesample waspredominantlycomposedofyoung,singlewomenwithfairlylowlevels ofeducationalattainment.Nearlyhalfhadnotcompletedhighschool(44%). Womenwereaskedabouttheirhealthinsurancestatusasaproxyforsocio- economicstatus;only15%hadprivateinsurance,22%wereonMedicaid, andtherest(63%)hadnoinsurance.ParticipantswerepredominantlyAfri- can American with a smaller White/mixed-race sample. Approximately threequartersofthewomenhadchildrenyoungerthantheageof18.Most womenwereawaitingtrial,although20%wereservingacurrentsentence. Finally,womenwerechargedwithavarietyofcrimesandsometimeswere multiplycharged(ourcategorieswerenotmutuallyexclusive),butmosthad 140 CRIME & DELINQUENCY / JANUARY 2005 TABLE 1: Demographic Characteristics Mean (Range) or % Age 34.5 years (19-50 years) Marital status Never married 60% Married 13% Divorced/separated/widowed 27% Education Less than high school 44% High school grad/General Equivalency Diploma 31% Some college or trade school 25% Ethnicity African American 81% White 11% Other 8% Child younger than age 18 73% Living arrangements With family/friends/parents 65% In own house/apartment 28% Other 7% Legal status Awaiting trial 80% Serving sentence 20% Length of stay Awaiting trial 1.8 months (1-4 months) Serving sentence 3.7 months (1-12 months) Present charges/offense(s) Assault 18% Drug related 21% Theft/robbery/check or credit card fraud 33% Driving related 9% Violation of probation 16% Other 20% relativelybriefstaysinthejail.Wewereabletoobtainsomedemographic dataonthelargerpopulationofallwomenwhowereincarceratedatthejail duringtheyear2000,andoursamplewassimilar.Forthelargergroup,the mean age was 32.3 years (34.5 years in the present sample), 82% of the womenwereAfricanAmericanand15%White(comparedto81%and11% inthepresentsample,respectively),and75%oftheoverallpopulationwere awaitingtrialcomparedto80%ofthestudysample.Thetwogroupsdiverged oneducation.Inthelargerpopulation,27%hadlessthanahighschooledu- cation compared to 44% in the study sample, whereas 47% were listed as havinga12th-gradeeducationcomparedtoonly31%ofoursample.Therea- Green et al. / NEEDS OF WOMEN IN JAIL 141 sonfortheeducationdiscrepancyisunclear,butitmakesgeneralizationsto more educated inmates potentially less valid. Analyses of study variables showed no significant differences between AfricanAmericanandotherwomen.Wealsocomparedthesubsamplesof womenawaitingtrialtothoseservingsentences.Traumaexposurewasquite similarbetweenthetwogroups(5.4typesoftrauma,onaverage,forthose awaitingtrialand6.2forthoseservingsentences)aswellastheaveragenum- berofinterpersonaltraumatypes(3.2versus3.7).Therewerenosignificant differences between the samples on percentages of psychiatric disorders, drugabuse,parenting,orriskbehaviors.Thewomenawaitingtrialhadmore childrenonaverage(2.4comparedto1.6)andlowerpercentagesofanalco- holproblem(28%comparedto50%)butdidnotdifferoneducationormari- talstatus.Becausethedifferenceswereminorandthoseservingsentences were few, the groups were combined for the remainder of the analyses. Women in the study were also asked about their job training and work experiences.Nearlyhalfofthewomenreportedsomejobtrainingexperience priortotheirincarceration,andabouthalfofthoseenteringatrainingpro- gram completed it. About half of those receiving training were trained in someaspectofofficeworksuchasdataentry;othersweretrainedincosme- tology, assistant health technician positions, or manual labor tasks. Trauma Exposure Results of the trauma exposure, substance abuse, and mental health assessmentarepresentedinTable2.Forpurposesofcountingtraumaexpo- sure, the questions on the NCS measure and the additional corresponding questionswedeveloped(e.g.,“Evenifyoudidn’tthinkaboutitasabuse...”) wereaddedtogether.Similartootherstudies,ratesoflifetimetraumaexpo- surewereextremelyhigh.Intotal,98%ofthewomenhadbeenexposedtoat leastonecategoryoftrauma.Themostcommontraumaexposurewastovio- lenceperpetratedbyahusband,partner,orboyfriendwith71%reportingthis experience.Intotal,62%reportedhavingbeenexposedtochildhoodtraumas and 90% to at least one type of interpersonal trauma. Substance Abuse Substanceabusewascommon,ascanbeseeninTable2.Althoughone thirdofthesample(34%)reportedthattheydonotdrink,32%wereclassified bytheTWEAKashavinganalcoholproblem.Nearlythreequarters(72%) reportedrecentuseofanillicitsubstance,and74%reportedeitheranalcohol or substance abuse problem. 142 CRIME & DELINQUENCY / JANUARY 2005 TABLE 2: Trauma,Psychiatric Disorders,and Substance Abuse % Affected Childhood trauma Sexually molested 48% Physically abused 26% Neglected 25% Any childhood trauma 62% Other trauma Life-threatening accident 42% Fire, flood, or natural disaster 9% Witnessed someone injured or killed 58% Family member killed 58% Raped 58% Physically attacked/abused 57% Domestic abuse 71% Threatened with a weapon 55% At least one trauma 98% Substance abuse problemsa Alcohol problem 32% Drug problem 72% Marijuana 37% Cocaine, crack, heroin 60% Hallucinogens 10% Alcohol or drug problem 74% Psychiatric disorders Current major depressive disorder (MDD) 25% Dysthymia 12% Possible bipolar disorder 13% Current post-traumatic stress disorder (PTSD) 22% MDD, PTSD, or bipolar 36% a.Substance abuse assessed for the 6 months preceding incarceration. Mental Health Problems Althoughnotasfrequentassubstanceabuseproblems,ratesofthepsychi- atricdisordersstudiedwerehigherthanwouldbeexpectedinthecommunity. OnefourthofthewomenreportedcurrentMDDand22%hadcurrentPTSD. Twelvepercentscreenedpositivefordysthymiaand13%forbipolardisor- der.Addingtogetherthethreemajorcategories(excludingdysthymia),just more than one third had one of the psychiatric diagnoses. Sexual and Reproductive Behavior Womenwereanaverageageof16atthetimeoftheirfirstvoluntaryinter- course.Nearlyallhadbeenpregnantatleastonce(92%),manyhadmiscar-