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Messina N., Grella C.E., Cartier J. et al.
Journal of Substance Abuse Treatment: 2010, 38, p. 97–107.
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From the USA a rare randomised controlled trial of prison-based substance use treatment for women finds substantial benefits from replacing a standard prison therapeutic community programme with one based on extensive trauma-informed and gender-responsive elements delivered in an entirely woman-only environment.
Summary Compared to men, women starting treatment for substance use problems in prison are at a substantial disadvantage, yet prison-based treatment for women has typically not focused on women's specific needs. Also, many evaluations of prison therapeutic communities for women have been limited by non-random allocation to focal versus comparison treatments, small samples, lack of a comparison group, and a restricted set of outcomes – primarily reimprisonment. Without random assignment, the characteristics of women who volunteer for or are ordered in to treatment may differ from those of the comparison group in ways which bias outcomes.
This study addresses these shortfalls in the research. It was the first to conduct a randomised controlled trial in a prison setting to determine the relative effectiveness of a theoretically based and trauma-informed gender-responsive therapeutic community programme compared to a standard prison therapeutic community. 115 women in a Californian prison who volunteered for the trial were randomly allocated to one of the prison's two six-month therapeutic community programmes for substance use problems. One was adapted to incorporate the gender-specific elements described below, delivered by specially trained peers and staff in a female-only environment. The other was a more traditional therapeutic community programme which lacked these elements.
Participants completed baseline research assessments and over 80% completed follow-ups on average about nine months after leaving prison, and three quarters after about 15 months. Averaging 36 years of age, at the start of the study just 18% were currently married. Before imprisonment three quarters were not working. Most reported histories of sexual (55%) and physical (71%) abuse and depression (79%). A quarter met criteria for posttraumatic stress disorder and nearly all for substance abuse or dependence, primarily involving methamphetamine, which almost half had used daily prior to imprisonment. Second most common was cocaine. Despite random allocation, on several measures women allocated to the gender-responsive programme were at greater risk, differences taken in to account in the statistical analyses.
The gender-specific programme was based on understandings of women's psychological development in the context of relationships and connections to others. In contrast, models for men typically focus on separation and independence. Detailed below, its two curricula focused on services for women's specific needs, implemented in ways which promote psychological growth and prosocial behaviour, and tailored for women in the criminal justice system.
The first curriculum on recovery from addiction consisted of 17 sessions in four modules. Module 1 ('Self') explored what the 'self' is, addiction as a disorder of the self, sources of self-esteem, effects of sexism, racism, and stigma on a sense of self, and recovery as the growth of the self. In the relationship module women explored their roles in their families of origin, discussed myths and realities about motherhood and their relationships with their mothers, reviewed relationship histories, and considered how they could build healthy support systems. A sexuality module dealt with connections between addiction and sexuality and body image, sexual identity, sexual abuse, and fear of sex when sober. The spirituality module introduced spirituality, prayer, and meditation. Spirituality was understood in terms of transformation, connection, meaning, and wholeness.
Concerned with trauma, the second curriculum consisted of 11 sessions teaching women what trauma and abuse are, exploring typical reactions, and developing coping skills. In these sessions women began to understand how traumatising events in their past affected their lives and learnt coping mechanisms while focusing on personal safety within a strengths-based approach.
What the gender-specific programme was benchmarked against was a traditional approach which embodied (relative to the usual prison environment) positive attitudes towards the inmates and positive values to start a process of socialisation, using treatment staff to provide role models, many of whom were themselves recovering addicts.
At the follow-ups, several measures indicated that after both programmes psychological and social wellbeing had improved to roughly the same degree. So too according to the raw figures had the severity of drug and alcohol use and problems. However, after race and baseline marital status and employment had been taken in to account, women allocated to the gender-responsive programme had experienced significantly greater remission in their drug use and problems.
Similarly, though in favour of the gender-responsive programme (31% v. 45%), on the raw figures there was no significant relative improvement in reimprisonment. However, after race and baseline marital status and living situation (eg, whether homeless) had been taken in to account, over the follow-up period women allocated to the gender-responsive programme had been significantly less likely According to official records. The analysis also took in to account differences in the time that the women were 'free' to offend after release because not resident in one of the voluntary aftercare programmes offered by the prison. to be reimprisoned. Though not statistically significant, on average women allocated to the gender-responsive programme also stayed out of prison for several months longer.
They also participated more fully in the prison's voluntary aftercare arrangements. After race and baseline marital status and living situation had been in to account, according to records they were significantly more likely to complete the initial residential element (raw figures 54% v. 36%) and also (non-significantly) stayed longer and were less likely to drop out.
This study's findings are particularly promising given the severity of the addiction and criminal histories of the sample, indicating beneficial impacts from integrating gender-responsive elements in prison-based treatment for women and in particular the two tested curricula. After going through this programme, compared to usual treatment women were substantially more successful while out on parole, sometimes to a statistically significant degree once other factors had been taken in to account. Among these improvements were drug use, reimprisonment, and aftercare completion.
For practical and ethical reasons, random assignment of participants to either a treatment or control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. group is rare in evaluations of prison programmes. The primary strength of this study was random assignment, allowing all participants to receive at least the standard treatment, with some participants receiving enhanced treatment designed specifically for female offenders. This rigorous design strengthens confidence that the findings as they relate to this sample and these programmes really do reflect an impact of the tested programme. The study was further strengthened by the large percentages of women who met criteria for substance use disorder, a control group receiving standard treatment, standardised outcome measures, two post-prison follow-up points, and reliance on official records as well as the offenders' own accounts.
It is however difficult to disentangle the effects of the different elements of the prison programme and participation in aftercare. Qualitative findings showed that women in the gender-responsive programme were extremely invested in and satisfied with their treatment (especially session topics regarding intimate partners, family roles, and trauma histories), felt supported by other group members, and promoted continued use of these materials and protocols in the prison. Overall treatment satisfaction, a sense of safety and comfort, and a supportive peer environment, may have increased adherence to treatment and recovery, which may in turn have led to reductions in drug use, increased retention in aftercare, and reductions in reimprisonment.
commentary Results from this all-enveloping female-only, female-focused environment contrast with less convincing results from another cognitive-behavioural therapy programme for female US prisoners suffering both substance dependence and post-traumatic stress disorder. In the less successful initiative, gender/trauma elements constituted a relatively minor and – since the core case management role was conceded to the prison programme – perhaps peripheral add-on to an already extended, intensive, and potentially powerful residential programme. It may also be relevant that in this study these was no prison-supplied residential aftercare option, one which in the featured study the women from the tested programme more fully availed themselves of. Without this opportunity for deeper engagement with treatment fostered by a specialist prison programme to express itself in attendance at a post-prison residential programme, the gains made in prison could quickly evaporate once offenders leave.
The authors' caution that what caused the differences in outcomes was unclear. Apart from the features mentioned, another possibility is the re-moralisation of prison staff newly trained in impressive and extensive programmes by the developer of the programmes, and the consequent re-moralisation of offenders assigned to this practice innovation. Such factors seem to have an influence over and above the impact of the actual content of an intervention.
The great advance made by this study was effectively to implement random allocation, which it did by allocating women with an even criminal justice number to one programme and with an odd one to the other, meaning allocation could also be checked. When in 2008 the literature on substance use treatment for women offenders was reviewed, no randomised studies were found. But the conclusions reached from this imperfect corpus of research pointed in the direction of a programme such as that tested in the featured study. The reviewers characterised optimal treatments for women offenders as providing a continuum of prison and community-based services with individualised care based on a thorough assessment on entering prison. Gender-specific programmes that integrate substance abuse treatment and trauma-related mental health care were preferred to mixed-gender programmes. Such programmes should, argued the reviewers, emphasise empowerment, building social support networks, and adopt a collaborative rather than authoritarian approach. Upon community re-entry, women offenders need safe, affordable housing, and continued treatment – in the featured study offered routinely by the prison, but more often taken up and stayed in longer by women who had experienced gender-response treatment while in prison.
It is however unfortunate that despite random allocation some substantial differences remained between women in the two sorts of therapeutic community. Only by adjusting the results to take account of these differences was the study able to produce statistically significant results. This a second-best solution compared to randomisation which truly (as intended) produces equivalent caseloads for the two programmes.
Thanks for their comments on this entry in draft to Nena Messina of the UCLA Integrated Substance Abuse Programs in Los Angeles, USA, and to Gail Gilchrist of the University of Greenwich in England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 07 January 2013. First uploaded 21 December 2012
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