The author(s) shown below used Federal funds provided by the U.S.

Department of Justice and prepared the following final report:

Document Title: Treatment of Incarcerated Women With

Substance Abuse and Posttraumatic Stress

Disorder, Final Report

Author(s): Caron Zlotnick Ph.D.

Document No.: 195165

Date Received: July 03, 2002

Award Number: 99-WT-VX-0004

This report has not been published by the U.S. Department of Justice.

To provide better customer service, NCJRS has made this Federallyfunded grant final report available electronically in addition to

traditional paper copies.

Opinions or points of view expressed are those

of the author(s) and do not necessarily reflect

the official position or policies of the U.S.

Department of Justice.
Program Director (Last, first, middle): Zlotnick, Caron 

Final Report 

Grant Award #: 1999-WT-VX-0004 

Project Period: 6/1 /I 999-3/32/2002 r), 

Treatment of Incarcerated Women with Substance Abuse 

and Posttraumatic Stress Disorder 

Caron Zlotnick, Ph.D.l 

--- c- I . % 

PROPERTY OF 

National Criminal Justice Reference Service (NCJRS) 

/-- -- Box 6000 

Rockville, MD 20849-6000 . 

1 Dr. Zlotnick is an assistant professor at Brown University, Department of 

Psychiatry and Human Behavior, Butler Hospital, 345 Blackstone Boulevard, 

Providence, Rhode Island, 02906. 

This project was supported by grant 99-WT-VX-0004 awarded to Butler Hospital, 

from the National Institute of Justice. Findings and conclusions of the research reported 

here are those of the author and do not necessarily reflect the official position or policies 

ef theU.S. Department of Justice. 

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This document is a research report submitted to the U.S. Department of Justice. This report has not 
Program Director (Last, first, middle): Zlotnick, Caron 

The dramatic increase in numbers of the female prison population since 1980 has 

been attributed to drug offenses, increasingly punitive responses to these crimes, and the 

.lack of viable treatment for these women (Bloom, 1994). Between 1990-1996, the rate of 

women’s drug possession convictions increased by 41 YO and drug trafficking convictions 

rose by 34% (U.S. Department of Justice, 1999a). A 1997 survey of State prisoners 

documented that over 40% of female inmates were under the influence of drugs at the 

time of their offense, compared to 32% of male inmates (U.S. Department of Justice, 

1999b). In addition to high rates of drug use among women prisoners, incarcerated 

women report extensive histories of interpersonal violence (Singer et al., 1995). The high 

rates of recidivism among women prisoners has been explained, in part, by the use of 

illegal substances compounded by high levels of physical and sexual abuse (Bloom, 

1994). Thus, the use of illegal substances and interpersonal victimization appear to play 

key roles in the lives of women prisoners. 

Besides high rates of substance use and trauma among incarcerated women, 

there are other reasons to conduct research on the development and testing of new 

treatments for incarcerated women with both disorders. These are: 1) A dual diagnosis 

of posttraumatic stress disorder (PTSD) and substance use disorder (SUD) is associated 

treatment that address the specific clinical needs of incarcerated women with comorbid 

PTSD and SUD have been developed or systematically evaluated. 

.with a more severe course than would occur with either disorder alone. 2) To date, no 

Prevalence rates for drug abuse or dependence in women prisoners range from 

26% to 63%, and alcohol abuse or dependence rates range from 32% to 39% (Jordan et 

al., 1996; Teplin et al., 1996; Daniel et al., 1988). Current drug abuse or dependence 

rates range from 30% to 52%, and alcohol abuse or dependence rates range from 17% 

to 24% (Jordan et al., 1996; Teplin et al., 1996). Women inmates are five to eight times 

more likely to abuse alcohol than women in the general population, ten times more likely 

to abuse drugs and 27 times more likely to use cocaine (Covington, 1998; Desjardins et 

al., 1992; Jordan et al., 1996; Teplin et al., 1996). According to the Center for Substance 

Abuse and Treatment (1 997), “up to 80% of all female offenders in some state prison 

now have severe, long-standing substance abuse problems,” (p. 2). Furthermore, in 

several studies of women inmates, the most common offenses for incarceration were 

adrug-related crimes (Covington, 1985; Inciardi, 1987; Jordan et al., 1996; Silverman, 

1982). Biron et al. (1995) found that 60.7% of women inmates used at least one 

substance on the day of the offense, and over 84% report drugs played a role in the 

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criminal activity (Biron et al., 1995). 

Prevalence rates of PTSD in the female prison population have been less well 

.studied compared to those of SUD. The only study, to date, to examine the rates of PTSD 

in women prisoners found that among female jail detainees awaiting trial, PTSD was the 

most common disorder, besides SUD, with prevalence rates of 33.5% for lifetime PTSD 

and 22.3% for current PTSD (Teplin et al., 1996). These rates of PTSD among women 

prisoners are more than three times the rates of PTSD reported in a community sample of 

women (Kessler et al., 1995). Further, research has shown that 78 to 85% of incarcerated 

women have experienced at least one traumatic event (Jordan et al., 1996; Lake, 1993; 

Singer et al., 1995) compared to 69% of the general female population (Resnick et al., 

1993). In particular, childhood abuse is strongly associated with PTSD (Rowan et al., 

1993) and is common-among incarcerated women, with 23 to 48% of women prisoners 

. reporting such experiences (Greenfeld et al., 1991 ; Singer et al., 1995). 

The co-occurrence of SUD and PTSD among incarcerated women is high 

(Zlotnick, 1997); a finding that is consistent with research with community samples that 

have found that women with current PTSD have a 1.4 to 5.5 times higher risk for comorbid 

SUD compared to women without PTSD (Helzer et al., 1987; Kilpatrick et al., 1996; 

OKessler et al., 1995; Kulka et al., 1990). In the study of women prisoners, 56% of the 

incarcerated women with lifetime substance abuse disorder met criteria for current PTSD. 

Also, of those women with current PTSD, all but one woman prisoner reported a lifetime 

substance abuse disorder. 

For individuals with PTSD or those with SUD, psychiatric comorbidity has been 

identified as a poor prognostic factor. Compared to substance abusers without PTSD, 

studies have found that those patients with PTSD have poorer treatment compliance, a 

poorer course of substance abuse, more inpatient admissions, more medical problems, 

higher rates of recidivism, greater criminal behavior, and expect fewer benefits from 

discontinuing substance use (Brady et al., 1994; Brown et al., 1994; Druley & Pashko, 

1988; Ouimette et al., 1997). Several studies have reported that a dual diagnosis of 

PTSD and SUD is associated with use of the most severe drugs (Cottler, et al., 1992; 

Dansky et al., 1995; Goldenberg et al., 1995). Further, patients with SUD plus PTSD 

evidence significantly more avoidant and arousal symptom clusters and greater sleep 

e isturbances than those with SUD alone (Saladin et al., 1995). Also, research that has 

compared patients with PTSD and SUD to those with SUD alone has found that the 

former report poorer psychosocial functioning in that they have more interpersonal 

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Program Director (Last, first, middle): Zlotnick. Caron 

problems (Najavits et al., 1995), homelessness (Smith et al., 1993; Paone et al., 1992), 

unemployment (Ouimette et al., 1997), and maltreatment of their children (Famularo et al., 

.I 992). 

Several authors have emphasized the need to integrate the treatments of PTSD 

and SUD to better meet the specific needs of these patients and in particular, alleviate 

suffering sooner (Brady et al., 1994; Brown et at., 1994; Evans & Sullivan, 1995; Fullilove 

et al., 1993; Kofoed et al., 1993; Ouimette et al., 1997). The rationale for the development 

of treatments that target concurrently the symptoms of PTSD and SUD is based on / 

research findings that this dual diagnosis is characterized by a more severe course and 

greater psychosocial impairment than would occur with either disorder alone (see section 

above). Thus, by not addressing the PTSD symptoms early in treatment, there is the risk 

of relapse of SUD and recidivism. 

A limited number of treatment approaches have been developed or tested for this 

dual diagnosis. Of the four manualized psychosocial treatments that have been 

developed and empirically tested thus far, all fit either a coping skills model, e.g., Abueg’s 

12-session relapse prevention model for veterans with alcoholism (Abueg, 1994) and 

Najavits’ 25-session Seeking Safety: A Cognitive-Behavioral Psychotherapy (SS) 

.(Najavits, 2002) (described in more detail below), or a combination of coping skills plus 

exposure. The combination of coping skills plus exposure is represented by Brady and 

colleagues (Brady et al., 2001) using a combination of in vivo and imaginal exposure plus 

relapse prevention; and Triffleman and colleagues’ Substance Dependence Posttraumatic 

Stress Disorder Therapy (Triffleman et al., 1999) using relapse prevention plus in vivo 

exposure, without imaginal exposure. There are several reasons why an exposure-based 

treatment may not be suitable for incarcerated women with PTSD and SUD. Triffleman 

and colleagues (1 999) recommend that their treatment may not be suitable for survivors of 

childhood sexual abuse who can have difficulties with relationships and maintaining selfsafety; childhood sexual abuse and the associated features are frequently found among 

incarcerated (Jordan et al., 1997; Zlotnick, 1997; Zlotnick, 1999). Furthermore, many 

experts have asserted that an exposure-based treatment for survivors of childhood abuse 

can “magnify the horror” and result in decompensation (Herman, 1992). Support for this 

view is found in the poor treatment response to trauma-focused groups by highly 

*distressed women (Follette et al., 1991), and in reports from the clinical literature that high 

drop-out rates and increased levels of anxiety are common in these groups (Goodman & 

Nowak-Scibelli, 1985). In one trauma disclosure group for survivors of sexual abuse, the 

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authors reported that 29% of the group participants showed an increase in their level of 

psychological distress after the intervention (Roberts & Gwat-Yong, 1989). The resulting 

*exacerbation of symptoms has been attributed to deficits in self-soothing and affect 

regulation; common features of incarcerated women, especially among those with PTSD 

or histories of childhood abuse (Jordan et al., 1997; Zlotnick, 1997; Zlotnick, 1999). 

Consistent with this notion that exposure treatment may be overwhelming to some 

individuals, the treatment study by Brady and colleagues (2001) in which patients with 

SUD and PTSD received exposure treatment, the majority of patients (61 54%) did not 

meet the minimum dose of the treatment. 

Despite the obvious need for effective SUD treatment programs in prison settings, 

the research literature is limited and little research supports the effectiveness of prison 

substance abuse treatment programs (Leukefeld & Tims, 1992). Results of substance 

abuse treatment efforts with the criminal justice population are mixed so treatment 

recommendations are limited. For instance, the most commonly published prison 

substance abuse treatment studies are based on the therapeutic community (TC) 

approach. In two studies that evaluated a modified TC for prison'inmates (Field, 1985; 

1989), participants showed enhanced self-esteem, decreased psychiatric impairment, and 

.reduced criminal activity and recidivism. In another study evaluating a TC program in the 

correctional system (Wexler et al., 1988; 1990), TC participants showed no better 

outcomes than counseling program participants, milieu therapy program participants, and 

no treatment participants. Most studies are flawed with serious methodological and 

design problems including a lack of adequate controkomparison groups (e.g., Field, 

1985; 1989). Even in studies which included comparison groups (e.g., Lowe, 1997; 

Wexler et al., 1988; 1990) participants were not randomly assigned and therefore internal 

validity was compromised. Further, follow-up intervals have not always been equal for all 

participants, important outcomes have not assessed, and few standardized measures with 

known psychometric properties have been used. 

Unfortunately, there is little research available describing the effectiveness of 

treatment for substance-abusing women prisoners (Henderson, 1998; Peters et al., 1997). 

Additionally, there is a dearth of treatments that have been developed specifically to meet 

the needs of women prisoners with SUD (Prendergast & Wellisch, 1995). The few 

.programs that exist in jails and prisons are often designed using approaches first 

developed for male inmates (Peters et ai., 1997). Numerous authors have advocated the 

need for gender-specific substance abuse treatments for incarcerated women based on 

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research findings, which have identified differential needs between male and female 

inmates (e.g., Austin et al., 1992; Henderson, 1998; Peters et al., 1997; Prendergast 

.&Wellisch, 1995). In particular, these authors have consistently stressed the importance 

of services for incarcerated women that address both drug abuse and victimization (Le., 

sexual violence and domestic violence). Finally, incarcerated women themselves appear 

motivated to receive services for both substance abuse and interpersonal violence. In a 

recent survey designed to assess the needs of incarcerated women, the service most 

frequently rated as very important was a service related to childhood physical and sexual 

abuse, and over 80% rated drug dependency/addiction-related services as very important 

(Sanders et al., 1997). 

acceptability of “SeekingSafety-(SS)”- treatment in a sample of incarcerated women with 

comorbid PTSD and SUD. More specifically, the aims of this study were to conduct an 

open feasibility trial of “Seeking Safety (SS)” treatment in a sample of 6 incarcerated 

women with SUD and PTSD, and to conduct a randomized controlled pilot study to 

evaluate the initial efficacy, feasibility, and acceptability of the proposed treatment as an 

adjunct to treatment as usual (TAU) compared to a TAU control group in a sample of 22 

@incarcerated women with comorbid PTSD and SUD. Regarding the randomized study, our 

The overall goal of this study was to evaluate the initial efficacy, feasibility, and 

primary hypothesis was that, compared to the TAU condition, women in the SS treatment 

condition will have less severe drugs and alcohol use as well as fewer PTSD symptoms 

and legal problems after the intervention, and at 6-weeks and 3-months postrelease. 

Seeking Safety: A Cognitive-Behavioral Psychotherapy (SS) treatment, which is based on 

an integration of the literature on SUD and PTSD, is a psychosocial treatment for women 

with comorbid PTSD and SUD, and is currently the treatment with the most efficacy data 

for this population (Najavits, 2002). SS treatment appears to be a promising intervention 

for incarcerated women with PTSD and SUD because the treatment targets many of the 

deficits found in this population that may interfere with their recovery and place these 

women at risk for reoffending, such as impulsiveness, anger dyscontrol, and maladaptive 

lifestyle activities, and teaches skills to manage these problematic behaviors. 

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Method 

Participants: 

All participants were drawn from the substance abuse treatment program 

(Discovery Program) in the minimum security arm of Women’s Facility of the Adult 

Correctional Institution (ACI) in Rhode Island. Discovery Treatment services is a 

voluntary, residential therapeutic program within the minimum security wing. The standard 

treatment is an abstinence-oriented program that focuses on substance abuse as a 

disease and as a maladaptive behavior pattern and on the 12-step model (AA, CA, NA). 

Treatment is primarily in group format in which all women are required to participate in 

order to remain in the program. 

e 

A research assistant reviewed all admissions to Discovery Program on a weekly 

basis for possible inclusion. All new admissions to the Discovery Program were 

approached approximately 12-14 weeks prior to their release date and told about the 

study. 

of the study were those women who met DSM-IV criteria for PTSD within the last month 

as determined by the Clinician Administered Posttraumatic Stress Disorder Scale-I 

.(CAPS-I) (Blake et al., 1990) and SUD within the last month and substance abuse or 

Of those potential recruits who consented to participate in the study, participants 

dependence prior to entering prison as determined by The Structured Clinical Interview for 

DSM-IV (SCID) (First et al., 1996). Participants were excluded if they a) were actively 

psychotic (hallucinating or delusional) at the time of recruitment, b) could not understand 

English well enough to understand the consent form or the assessment instruments, and 

benefit from the treatment, c) were diagnosed with organic brain impairment. 

Protocol: 

The first 6 participants received SS group treatment as an adjunct to the 

treatment provided by the Discovery Program (pilot study). The remaining participants 

were randomly assigned to either the control group (treatment-as-usual (TAU)) (N=lO) or 

received SS treatment as an adjunct to TAU (N=12) (experimental study). In the 

randomized trial, there were three groups of four women who received the group 

treatment rather than 6 women in a group. Based on our open trial, we found that due to 

the women’s severity of symptoms, the women required a level of attention that is not 

always possible to provide in a larger group. Sessions were 90-minutes long and were 

held twice a week for 12 weeks. All the participants received the standard treatment 

provided at Discovery Program. 

d) 

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The treatment groups were conducted by clinicians who worked as substance 

abuse therapists in the Discovery Program, and a clinical psychologist from Brown 

aniversity. One of the therapists was a cotherapist for all treatment groups in this study. 

All SS therapists received training in delivering SS therapy from Lisa Najavits (Dr. Najavits 

developed SS treatment), and received weekly supervision for the duration of the study 

from Dr. Najavits. 

SS Treatment: 

SS treatment draws upon the tradition of four literatures: cognitive-behavioral 

therapy of substance abuse (Beck et al., 1993; Carroll et al., 1991; Marlatt & Gordon, 

1985), PTSD treatment (Herman, 1992), women’s treatment (Jordan et al., 1991) and 

educational research (Najavits & Garber, 1989). Key facets of the treatment include the 

following. Each session focuses on developing a specific cognitive, behavioral, or 

interpersonal skill, with each skill designed to combat both disorders simultaneously. (For 

example, distraction techniques can be used for triggers of both drug abuse and PTSD.) 

The primary goals of the treatment are abstinence from substances and personal safety 

(e.g., from self-harm, HIV risk, domestic abuse). The treatment seeks to “translate” CBT 

into the language and themes of these patients, with therapy sessions on topics such as 

*honesty, asking for help, setting boundaries, integrating the split self, compassion, and 

taking good care of yourself. The treatment also focuses heavily on helping women avoid 

extreme relationship patterns that re-evoke past abusive relationships (e.g., 

overcompliance, enmeshment, isolation, and identification with aggressors that can lead 

to retraumatization). The treatment emphasizes therapeutic processes that offset PTSD 

and substance abuse (e.g., giving the patient “control” whenever possible, as both trauma 

and drug abuse typically diminished patients’ sense of control). The treatment is described 

in detail in Najavits (2002). 

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Zlotnick. Caron 

Measures: 

Assessments were conducted at pretreatment, posttreatment (during 

mncarceration) and 6- and 3-months postrelease for PTSD-related measures and 

measures of severity of substance abuse and legal problems were given at pretreatment, 

as well as the 6- and 12-weeks postrelease intervals. A bachelor level research assistant 

administered all the measures. The research assistant received training from the Clinical 

Assessment and Training Unit of Brown University Department of Psychiatry and Human 

Behavior, an established training program for these measures. This training protocol has 

led to high levels of reliability and has been used successfully in research projects for the 

past 6 years. 

Substance Use Disorder (SUD). 

The Addiction Severity Index.(ASI.)-(McLellan et-al:; 1992) was used to assess 

change in severity of substance abuse in the past 30 days. At intake the women were 

assessed for substance use in the 30 days prior to entering prison. The Structured 

Clinical Interview for DSM-IV (SCID (First et al., 1996) module on substance use was used 

to provide a diagnosis of alcohol use or dependence or drug abuse or dependence. Urine 

drug screens were completed at each postrelease point to detect recent drug use. Also, a 

*significant other (SO) was contacted and interviewed to provide collateral information 

about drug and alcohol use, at each postrelease period. 

Posttraumatic Stress Disorder (PTS 0). 

The Clinician Administered Posttraumatic Stress Disorder Scale-I (CAPS-I) (Blake 

et al., 1990) provided a diagnoses of PTSD as well as an assessment of the degree of 

PTSD symptoms (a composite score from the CAPS of the intensity and severity of PTSD 

symptoms). The CAPS-I has demonstrated sound psychometric properties and excellent 

diagnostic utility against the SClD PTSD diagnosis (Blake et al., 1990; Weathers et al., 

1993), with better psychometrics than the SClD for PTSD. 

Traumatic Event History. 

To assess lifetime history of trauma: the Trauma History Questionnaire (THQ; 

Greene, 1995) was given at pretreatment . This measure yields four frequency scores: 

physical, sexual, general disaster, and crime-related traumas. 

Legal Problems. 

The legal composite score from the AS1 was used to assess change in criminal 

activities. The legal composite index contains information about arrests, incarcerations, 

and engagement in criminal activity since release from prison. At intake the women were 

0 

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assessed for legal problems in the 30 days prior to entering prison. 

Patient Satisfaction with Treatment. 

At posttreatment, participants’ view of treatment was assessed on the Helping 

Alliance Questionnaire41 (Haq-ll; Luborky €4 al., 1996) and the Client Satisfaction 

Questionnaire (Attkisson & Zwick, 1982). Using a sample of patients with Cocaine 

Dependence Disorder, research has shown that the Haq-ll has excellent internal 

consistency, good convergent validity, and test-retest reliability (Lu borsky et al., 1996). 

At posttreatment, patients’ perceptions of the helpfulness of treatment I 

components of SS treatment was assessed with the End-of-Treatment Questionnaire 

(Najavitis, 1994). 

Therapist Assessments (Adherence). 

An Ad herence-Competence Scale (Najavitis & Liese, 1997) assessed therapist 

performance of specific interventions and group processes, each rated on adherence 

(amount of the behavior) and competence (skillfulness of the behavior), scaled -3 to +3. 

Ratings were completed by Dr. Najavits on all sessions. She found that the therapists 

who delivered SS treatment met at least adequate levels of competence and adherence. 

Data Analysis. e Several topics were addressed: (1) characteristics of the total participants sample 

at baseline, (2) participants’ satisfaction with SS treatment, (3) outcome of participants 

who received SS treatment (open trial study including participants from the pilot study and 

the experimental study), and (4) outcome of participants who received SS treatment as an 

adjunct to TAU compared to those in the control condition (TAU). Outcome was defined 

as substance use as determined by the SCID, degree of drugs and alcohol use as 

measured by the AS1 subscale for severity of alcohol and drug use, PTSD symptoms as 

measured by the composite score of the CAPS, and legal problems as measured by the 

AS1 subscale for legal severity. Percent of women who no longer meet criteria for a 

diagnosis of PTSD based on the CAPS was also considered. 

Topics 1 and 2 were addressed using frequency data. Topic 3 was analyzed via 

paired t-tests. Topic 4 was analyzed using a split-plot test analyses of variance (ANOVA). 

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Results 

The sample of incarcerated women who participated in the present study had 

*fairly similar sociodemographic and criminologic characteristics (i.e., age, ethnicity, type of 

offense, and length of sentence) to the population of incarcerated women in the Discovery 

Program at the Women’s Facility of the Adult Correctional Institution (ACI) in Rhode 

Island. Table 1 presents demographic and criminologic characteristics of the sample of 

incarcerated women who participated in this study (N=28). Table 2 shows the types of 

traumatic events reported (N=28). The mean age of first onset for PTSD was 15.0 

(SD=7.53) years of age and the mean age of first onset for SUD was 12.21 (SD = 4.4) 

years of age. The average length of abstinence from all substances was 11 months (SD = 

9.55). There were no significant differences between the participants in the pilot study 

and those participants in thee experimental study at intake in sociodemographic and 

criminologic characteristics, trauma histories, degree of PTSD symptoms, severity of 

substance use, and degree of legal problems at intake. Likewise, there were no 

significant differences between the treatment group and control group in these intake 

variables. There was a nonsignificant trend towards the control group reporting less 

severe substance use at intake (M=.29; SD=.216) than the treatment group (M=.42; 

@SD=.15) (t= 1.60, df= IO, 12, p = .07). A similar trend was found for severity of alcohol 

use at intake with the control group reporting less alcohol use at intake (M=.36; SD=.35) 

than the treatment group (M=.55; SD=.26) (t= 1.41, df= IO, 12, p = .08). 

Satisfaction with SS Treatment. 

There was a high degree of acceptability of the treatment in that 90% of the 

women who were approached to participate in the study agreed to participate in the study. 

All women who were offered treatment, began treatment. Only two women (1 1 Yo) 

dropped out of SS treatment. One woman dropped out of the group after the second 

session due to her decision to transfer out of Discovery Program, the substance abuse 

program in prison, and was therefore not allowed to attend any groups in the Program. 

One women left because she had pregnancy complications and was hospitalized, but 

posttreatment data were collected on this participant. Of the remaining women who 

received the SS treatment (N=l5), the attendance rate for the treatment was 83% of 

available sessions. Some women (65%) were unexpectedly released early, that is, before 

@the 12-week period prior to entry of the study. On average, women attended 14 sessions 

The mean ratings of the items on the End-of-Treatment Questionnaire (Najavits, 

with a range of 6 sessions to 24 sessions. 

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J 

Program Director (Last, first, middle): Zlotnick, Caron 

most helpful (items scaled from -3, very harmful to +3, very helpful), were all rated 2.50 or 

*above. More specifically, the therapist overall M = 3.00 (SD =O), the treatment overall M = 

2.83 (SD =.39) focus on the relationship between PTSD and SUD M = 3.00 (SD =O), 

helpfulness of treatment for PTSD M = 2.93 (SD =.29) and helpfulness of treatment for 

SUD M = 2.83 (SD =.39). The mean score on the Client Satisfaction Questionnaire 

(Attkisson & Zwick, 1982) (scaled 1 to 4 with 4 the highest) was 3.45 (SD=.52) for both 

therapists at the end of treatment. Patient alliance with treatment, as measured by the 

Helping Alliance Questionnaire41 (Luborsky et al., 1996) (scaled 1 to 6, with 6 the 

strongest alliance), showed a combined mean of 4.7 (SD=.53) for both therapists at the 

end of treatment. 

Outcome of Participants who received SS Treatment 

Of the women who received SS treatment (N=l8) there was follow-up data for 17 

woman at posttreatment, 16 at 6-weeks postrelease, and 15 at 3-months postrelease. 

Results showed that 9 (53%) of the women no longer met criteria for PTSD 

posttreatment, at 6-weeks postrelease 7 (44%) no criteria for PTSD at 3-months 

postrelease 46% no longer met criteria for PTSD. Paired t-tests found that for those 

@received SS treatment there was a significant decrease in PTSD symptoms from 

pretreatment to posttreatment (t=3.81, df = 17, p=.002), from pretreatment to 6-weeks 

postrelease (t=2.67, df = 16, p=.02) and from pretreatment to 3-months postrelease 

(t=2.25, df = 15, p=.04) (see Table 3). 

Within 6-weeks of release, 2 (1 1 %) of the woman returned to prison, and within 3- 

months of release 6 (33%) returned to prison. Only one instance occurred in which the 

urinalysis result was positive and the self-report was negative (at the 6-weeks follow-up). 

On the basis of this case’s positive urinalysis, she was categorized as a substance abuse 

user and her baseline data on the AS1 subscales of drug use and alcohol use for 6-weeks 

and 3-months postrelease were set at their intake value. During incarceration, random 

urine drug screens were given, and none of the women received a positive urinalyses. 

There were two instances in which the significant others report were positive for drug use 

and the self-report was negative (at the 3-months follow-up). Based on the self-report of 

substance use from the SClD and the results of the urinalysis, within the 6-weeks followup, 5 (29%) of the women reported the use of illegal substances and within 3-months one 

other women reported substance use. There were a total of 6 (35%) of the women who 

had reported using illegal substances within 3-months of release. Participants showed a 

a 

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 and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 

 been published by the Department. Opinions or points of view expressed are those of the author(s) 

This document is a research report submitted to the U.S. Department of Justice. This report has not 
I 

) 

Program Director (Last, first, middle): Zlotnick, Caron 

pretreatment to 6-weeks postrelease (tz6.09, df = 1, 15, p=.OOI) (tz3.06, df = 1, 15, 

ep=.002) (t=5.13, df = 15, p=.OOI), respectively, and to 3-months postrelease (t=4.61, df = 

1, 14, p=.OOI) (t=2.88, df = 1, 14, p=.OI) (t=4.16, df =I, 14, p=.OOI), respectively (see 

Table 3). 

Comparison of Outcome Between Participants who received SS Treatment and 

Control Group 

Three (30%) of the women in the control group dropped out of the study. A 2X 4 

split-plot test ANOVA was conducted with Time [pretreatment, posttreatment, 6-weeks 

postrelease, 3-months postrelease) X Treatment (treatment group (TX) (N=l2), treatment 

as usual (TAU) (N=7)), with time as a repeated measure and the dependent variable as 

- severity of PTSD symptoms. The split-plot test ANOVA on the outcome measures 

revealed a significant main effect for time for PTSD symptoms, F(2, 13) =7.47, p =.001 , 

and no significant Treatment X Time interaction for PTSD symptoms, F(2,13) =.37, p =.77. 

Only one instance occurred in which the urinalysis result was positive and the 

self-report was negative for the treatment condition (9.1 %). On the basis of this case’s 

positive urinalysis, she was categorized as a substance abuse user and her baseline data 

@on the AS1 subscales of drug use and alcohol use for 6-weeks and 3-months postrelease 

were set at their intake value. During incarceration, random urine drug screens were 

given, and none of the women received a positive urinalyses. Based on the self report of 

substance use from the SClD and the results of the urinalysis, within the 6-weeks 

postrelease follow-up, 4 (36%) of the 11 women in the treatment group and 2 (28%) of 

the 7 women in the control group reported using illegal substances and within 3-months 

postrelease, there was a total of 5 (45%) of the 11 women in the treatment group and 2 

(33%) in the control group (N=6) who reported using illegal substances. There were no 

significant differences between the two groups in use of illegal substances at 6-weeks 

(x2=.11, df= 1, p=.73) or within 3-months postrelease (x2=.23 2, df= 1, p=.63). 

In the control group, only 1 (10%) woman returned to prison within 3-months 

postrelease, whereas in the treatment group 6 (50%) returned to prison within 3-months 

postrelease. There was a nonsignificant trend towards women in the control group to be 

less likely to return to prison within three months than those in the treatment group 

*~2=4.02, df= I, pz.08). 

A series of 2X 3 split-plot test ANOVA was conducted with Time [pretreatment, 6- 

weeks postrelease, 3-moths postrelease) X treatment (treatment group (TX), Treatment 

Page 13 

 and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 

 been published by the Department. Opinions or points of view expressed are those of the author(s) 

This document is a research report submitted to the U.S. Department of Justice. This report has not 
Program Director (Last, first, middle): Zlotnick. Caron 

as usual (TAU)), with time as a repeated measure and the dependent variables as the AS1 

subscales of drug use, alcohol use, and legal problems. The ANOVA on the outcome 

*measures revealed a significant main effect for time for severity of drug use, F (2,13) 

=10.64, p =.002, and severity of alcohol use, F(2,13) = 5.64, p =.03. There was no 

significant main effect for the severity of legal problems, F(2,13) = 2.38, p =.I 1. There 

were no significant Treatment X Time interactions for the AS1 drug severity subscale, 

F(2,13) =.91, p =.43, the AS1 alcohol severity subscale, F(2,13) =,.64 p =.53, and the AS1 

legal severity subscale, F(2,13) =2.54, p =.I 1. i 

Page 14 

 and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 

 been published by the Department. Opinions or points of view expressed are those of the author(s) 

This document is a research report submitted to the U.S. Department of Justice. This report has not 
Program Director (Last, first, middle): Zlotnick, Caron 

Discussion 

Preliminary findings from the open clinical trial showed: 1) initial acceptability 

*and feasibility of the project (Le., appropriate participants were recruited and retained), 2) 

the treatment appears to be highly appealing to our target sample (there was very strong 

alliance and satisfaction with SS treatment and retention rate in treatment was high), and 

3) the treatment has the potential to be helpful (treatment had some favorable outcomes 

and the women felt helped by the treatment). More specifically, in the open trial of 

women who received SS treatment as an adjunct to TAU, there were significant 

improvements in PTSD symptoms from pre- to posttreatment, which were maintained 

through three-month after release . At 6-weeks postrelease, there were significant 

decreases in severity of substance use and degree of legal problems. Only 35% of the 

women within 3-months after release had used an illegal substance. The treatment, 

however, did not reduce the recidivism rate below the existing recidivism rate for women 

within the prison setting of the study. 

This present study is the first empirical study to examine the effects of a treatment 

for women prisoners with comorbid PTSD and SUD. The findings from the open clinical 

trial that women who received SS treatment as an adjunct to TAU showed a significant 

*improvement in posttraumatic symptoms and that nearly half of the women no longer met 

criteria for PTSD three months after treatment suggest that the treatment had an impact 

on one of the main target areas it was designed to affect, PTSD. PTSD is usually a 

chronic disorder and individuals who receive treatment take, on average, 36 months to 

recover from their PTSD (Kessler et al., 1995). The impact of SS treatment on substance 

use was difficult to interpret because most of the women were in a controlled environment 

(Le., prison) for the 6-weeks to 3-months follow-up period. In an open clinical trial study of 

SS treatment in a sample of community women with comorbid PTSD and SUD (Najavits 

et al., 1998), there were significant decreases in PTSD symptoms and substance use at 

the 3-month follow-up. In comparing the latter study (Najavits et al., 1998) with the current 

study in terms of participants' severity of substance use, legal problems, and 

psychological difficulties at intake as measured by the ASI, the women prisoners at intake 

reported substantially more problems in all three domains than the women in the 

community sample. Furthermore, in the community sample used in the Najavits et al.'s 

tudy (1998), only 59% had drug dependence (compared to all the women prisoners in the ." current study) and cannabis was the most frequently reported type of substance type (in 

contrast to cocaine in the current study). The differences in severity levels of substance 

Page 15 

 and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 

 been published by the Department. Opinions or points of view expressed are those of the author(s) 

This document is a research report submitted to the U.S. Department of Justice. This report has not 
Program Director (Last, first, middle): Zlotnick, Caron 

use and response to SS treatment between the two study samples (i.e., most women in 

the present study returned to prison) suggest that women prisoners may have different 

ereatment needs for their SUD compared to women in the community, such as, a 

treatment of a longer duration than the existing SS treatment or a different treatment 

modality. 

The present study showed that the treatment was highly appealing to women 

prisoners. The retention rate was higher than most studies and higher than other studies 

of substance abuse populations (Crits-Christoph et al., 1996) and higher than the study by 

Najavits et al. (1998). Using the same definition of completer as Najavits et al. (1998) 

(i.e., a completer of SS treatment was defined as a participant who attended six or more 

sessions (Najavits et al.; 1998)), the retention rate was 80% for the current study 

- I compared to 63% in the study by Najavits et al., (1998). This definition of “completer” as 

attending at least 25% of sessions is also more stringent than many other studies of 

substance abuse samples. Moreover, participants in this study completed 85% of 

available sessions compared to 67% of available sessions in the study by Najavits et al 

(1 998). The strong participant alliance and satisfaction data suggest that participants in 

the present study felt helped by receiving SS treatment. These results also suggest that 

@women prisoners are able to engage in treatment and view treatment as beneficial, 

despite their marked impairment. 

While the current form of SS treatment as an adjunct to TAU appears a promising 

approach for incarcerated women with comorbid PTSD and SUD, the findings of the open 

trial have several limitations. Without a control group to show that any gains occurred at a 

significantly higher rate among those women who received the SS treatment compared to 

a non-SS treatment group, results remain tentative. The improvement in the PTSD 

symptoms may have been a function of time or the natural course of the disorder for this 

population of women. The long-term benefits of the treatment are unknown as the study 

follow-up period was limited to 3 months after release. The small sample limits any 

generalizability of the findings to other incarcerated women in different prison settings. 

treatment as an adjunct to TAU and the TAU group on any of the indices of interest. One 

explanation is that, due to the small sample size in the control group, significant 

The present study found no differences between the group that received SS 

ifferences between the treatment and the control groups were difficult to detect. 

Furthermore, there was a 30% attrition rate in the control group, which raises the 

possibility that the control group was not representative of women who received TAU. 

r)d 

/ 

I 

Page 16 

 and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 

 been published by the Department. Opinions or points of view expressed are those of the author(s) 

This document is a research report submitted to the U.S. Department of Justice. This report has not 
Program Director (Last, first, middle): Zlotnick, Caron 

Alternatively, since the SS treatment was an adjunct treatment, perhaps SS treatment did 

not contribute beyond the effects of the existing substance use treatment (Discovery 

@Program) that prisoners received during incarceration. The nonsignificant trend towards a 

lower recidivism rate for the control group than the treatment group may be explained by 

the fact that the treatment group appeared to have a greater severity of drug use than the 

control group one-month prior to prison, which may have put the treatment group at 

greater risk than the control group for recidivism. 

Our preliminary finding of no difference between the treatment group and control 

group in outcome is similar to a study that examined the effects of a TC program in the 

correctional system (Wexler et al., 1988; 1990), which found that TC participants showed 

no better outcomes than counseling program participants, milieu therapy program 

participants, and no treatment participants. A series of studies on TC programs provided 

during incarceration have found that at follow-up (period ranged from 6-23 months), postrelapse and recidivism rates were significantly lower for participants of the TC program 

compared to a nontreatment comparison group (Hiller et al., 1999; lnciardi et al., 1997; 

Nielsen et ai., 1996). More specifically, 76% of those who completed the prison-based TC 

treatment program had used drugs in the 18-month period and 55% had been rearrested. 

*An untreated comparison group had the poorest outcomes; 85% had relapsed to drug use 

and 56% had been rearrested for a new offense (Inciardi et ai., 1997). Compared to SS 

treatment in the present study, which consisted of 24 sessions and took place over a 12- 

week period during incarceration, the duration of TC programs are generally 6- to 9- 

months and includes supervised outpatient care. 

The finding in the present study that many women who received SS treatment 

returned to prison suggest that there may have been little transfer of skills learnt in SS 

treatment during incarceration to the "real world." Numerous researchers have 

recommended a continuum of care for substance abusers in the criminal justice system 

because these clients often face a wider range of problems than other substance abusing 

clients, such as the perceived stigma of a criminal record, dual problems of recovery and 

reentry into society (Barthwell et al., 1995; Hiller et al., 1999; Peters et at., 1997). 

Therefore, if at postrelease, women are not actively engaged in treatment, they are at 

increased risk of resorting to the maladaptive behaviors, such as substance use, that 

recipitated their incarceration (Lake, 1993). Perhaps an expansion of SS treatment to 

the postrelease period may substantially improve upon the initial findings of the current 

study. 

0" 

i 

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 been published by the Department. Opinions or points of view expressed are those of the author(s) 

This document is a research report submitted to the U.S. Department of Justice. This report has not 
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This document is a research report submitted to the U.S. Department of Justice. This report has not 
J 

Program Director (Last, first, middle): Zlotnick. Caron 

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 and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 

 been published by the Department. Opinions or points of view expressed are those of the author(s) 

This document is a research report submitted to the U.S. Department of Justice. This report has not 
Program Director (Last, first, middle): Zlotnick, Caron 

Table 1 Demoqraphic and Criminoloqic Characteristics of Incarcerated Women (N=28) 

Characteristics 

Race 

White 

African American 

Hispanic 

Other 

Age 

M (SD) 

Education, 

High School Graduate 

Some High School 

Below 9th Grade 

Marital status 

Married 

Separated 

Divorced 

Never married 

Living As Separated 

First time in prison 

Nature of Crime 

NO. (Yo) 

I9 (67.9) 

2 (7.1) 

3 (1 0.7) 

4 (14.3) 

30.9 (4.53) 

9 (32.1) 

13 (46.4) 

6 (21.4) 

2 (7.1) 

3 (10.7) 

5 (1 7.9) 

17 (60.7) 

4 (14.3) 

1 (3.6) 

@ Zzmeanor 

Number of previous arrests with conviction 

M (SD) 

11 (39.3) 

17 (60.7) 

7.36 (9.81) 

Page 25 

 and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 

 been published by the Department. Opinions or points of view expressed are those of the author(s) 

This document is a research report submitted to the U.S. Department of Justice. This report has not 
Program Director (Last, first, middle): Zlotnick, Caron 

Table 2 Types of Reported Trauma and Subtypes of Substance Use Disorders among 

.Incarcerated Women (N=28j 

- N - % 

Trauma Variables 

Sexual abuse 27 96.4 

Physical abuse 25 89.3 

Repeated trauma 28 I00 

Age of first trauma M (SD) 

Subtvpes of Substance Use Disorders 

8.50 (5.54) 

Substance Dependence 28 

Lifetime-Polysubstance Use Disorder 

Preferred Current Substance 

Current* Polysubstance Use Disorder 7 

Cocaine 12 

Alcohol and Drugs 

Number of Periods of Abstinence M CSD) 

* Current=within 30 days prior to entering prison. 

100 

25.0 

17 60.7 

42.9 

6 21.4 

2.79 (2.81) 

Page 26 

 and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 

 been published by the Department. Opinions or points of view expressed are those of the author(s) 

This document is a research report submitted to the U.S. Department of Justice. This report has not 
Program Director (Last, first, middle): Zlotnick, Caron 

Table 3 The Outcome of Particbants Who Received Seekina Safetv: A Coanitive-Behavioral Psvchotheraw: 

@ Chanae Over Time 

Measure 

CAPS 

PTSD symptoms 

AS I 

Drug use composite 

.17 (.11) 

0 Alcohol use composite 

.28 (.29) 

Legal problems composite 

.20 (.181 

ASI=Addiction Severity Index 

Pre-TX to Post TX 

N N N 

M (SD) M (SD) M(SD) MBD) M (SD) M CSD) 

Pre-TX to 6 weeks F/U Pre-TX to 3-months F/U 

17 16 15 

70.5 (20.4) 47.8 (23.8) 69.62 (20.6) 50.0 (28.1)69.62 (20.6) 50.(29.1) 

"-~ * 

16 15 

.39 (.14) .16 (.lo) .37 (.13) 

16 

.55 (.27) .27 (.25) 

16 15 

54 (.24) .24 (.17) 

15 

.55 (28) 

56 (.23) 

i' 

CAPS=Clinician Administered Posttraumatic Stress Disorder Scale 

PTSD=Posttraumatic Stress Disorder 

Page 27 

 and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 

 been published by the Department. Opinions or points of view expressed are those of the author(s) 

This document is a research report submitted to the U.S. Department of Justice. This report has not 
Program Director (Last, first, middle): Zlotnick, Caron ~ 

to the Control Group Over Time 

Measure Pre-TX 

Tx. group Control group 

N N 

M (SDI M ISD) 

CAPS 

PTSD symptoms 

12 10 

72.1(20.69) 67.16(29.49) 

AS1 

Drug use composite 

12 10 

.38 (.15) .28(.22) 

Alcohol use composite 

12 10 

52 (.26) .35 (. ) 

Legal problems composite 

12 10 

52 (.25) .37 (.22) 

Post TX 6 weeks Follow-Up 

Tx group Control group 

N N N N 

M (SD) M ED) M ISD) M(SD) 

Tx group Control group 

12 10 11 7 

46.0(25.67) 46.0(39.40) 38.83(28.93) 48.40(37.66) 

11 7 

.19(.09) .I 6(.15) 

11 7 

.23(.25) .22(.29) 

11 7 

.32(.22) .31(.30) 

3-months Follow-Up 

Tx group Control group 

N N 

M(SD) M (SD) 

10 6 

35.6(32.17) 49.10(29.49) 

10 6 

.20(.13) .14(.12) 

10 6 

.31(.34) .24(.30) 

10 6 

.19(.20) .28(.22) 

ASI=Addiction Severity Index 

CAPS=Clinician Administered Posttraumatic Stress Disorder Scale 

PTSD=Posttraumatic Stress Disorder 

PROPERTY OF 

National Criminal Justice Reference Service (NCJRS) 

Box 6000 

Rockvi!le, MD 20849-6000 

Page 28 

 and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 

 been published by the Department. Opinions or points of view expressed are those of the author(s) 

This document is a research report submitted to the U.S. Department of Justice. This report has not 
KEY PERSONNEL 

came Organization Role on Project 

Caron Zlotnick, Ph.D. Butler Hospital/ Brown University P.I. 

Lisa Najavits, Ph.D. McLean HospitaVHarvard University Consultant 

Damaris J. Rohsenow, Ph.D. Brown University Consultant 

i 

Page 29 

 and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 

 been published by the Department. Opinions or points of view expressed are those of the author(s) 

This document is a research report submitted to the U.S. Department of Justice. This report has not