Substance Abuse

Treatment for

Women Offenders

Guide to Promising Practices

Technical Assistance Publication Series

23

Patricia A. Kassebaum

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

Rockwall II, 5600 Fishers Lane

Rockville, MD 20857
This publication is part of the Substance

Abuse Prevention and Treatment Block

Grant technical assistance program. All

material appearing in this volume except

quoted passages from copyrighted sources

is in the public domain and may be reproduced or copied without permission from

the Center for Substance Abuse Treatment

(CSAT) or the author. Citation of the

source is appreciated.

This publication was written by Patricia

A. Kassebaum of Johnson, Bassin & Shaw,

Inc. under contract 270-94-0002 from the

Substance Abuse and Mental Health

Services Administration (SAMHSA).

Patricia Rye, J.D., M.S.W., of CSAT served

as the Government project officer during

the development and writing of this book.

Gayle Saunders of CSAT served as the

Government project officer for the review

and production stages of the book under

contract 270-95-0016 from SAMHSA.

The opinions expressed herein are the

views of the author and do not necessarily

reflect the official position of CSAT or any

other part of the U.S. Department of

Health and Human Services (DHHS).

DHHS Publication No. (SMA) 99-3303

Printed 1999
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Advisory Panel Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

PART I—SETTING THE STAGE FOR TREATMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Chapter 1 — Women Offenders and Addiction: Research Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Approach of the Center for Substance Abuse Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Chapter 2 — Specific Treatment Approaches for Women Offenders . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Why Women Need Specific Treatment Approaches. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Overview of CSAT’s Prison and Jail Programs for Women . . . . . . . . . . . . . . . . . . . . . . . . . 18

Recommendations for Treatment Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Critical Role of Corrections Administrators. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Chapter 3 — Systems Planning for a Continuum of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Background to Collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Advantages of a Systemic Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Types of Community-based Systems Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

CSAT’s Recommended Approaches for Establishing

Networks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

PART II—DESIGNING TREATMENT PROGRAMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Chapter 4 — Clinical Issues in Treating Women Offenders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Clinical Issues Affecting Substance Abuse in Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Additional Clinical Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

In-Program Sanctions and Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Interventions by CSAT-supported Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Chapter 5 — Program Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Selecting the Appropriate Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Treatment Modalities in Criminal Justice Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Types of Approaches and Program Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Important Programmatic Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Adapting Models to Women’s Needs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Modifying the Common Male Treatment Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

iii

Contents
PART III—STAGES OF TREATMENT PLANNING: THE ACTION STEPS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Chapter 6 — Stages in the Treatment/Accountability 

Continuum of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Stage 1: Screening and Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Pre-Screening for Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

Instruments for Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Screening for Admission to Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Including Women With Co-Occurring Disorders

in Drug Treatment Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

Assessment Process for Jail and Prison Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Assessment Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

Promising Assessment Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Stage 2: In-Custody Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

Planning the Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

Treatment Recommendations and Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

Stage 3: Transition/Pre-Release Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Case Management in the Pre-Release Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Important Principles in Transition Planning/Supervision. . . . . . . . . . . . . . . . . . . . . . . 110

Stage 4: Post-Release Treatment and Continuing Care. . . . . . . . . . . . . . . . . . . . . . . . 113

Components for Post-Release Transition 

to the Community. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

Various Paths for Women Upon Release. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

Issues Concerning Treatment in the Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

Case Management in the Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

Women’s Need for Continuing Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

Strategies for Providing Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

Chapter 7 — Critical Issues in Implementing Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

Engaging in a Systematic Planning Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

Selecting an Effective Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130

Gaining Support From the Prison Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130

Selection and Role of Corrections Security Staff. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134

Selection and Training of Substance Abuse Treatment Staff . . . . . . . . . . . . . . . . . . . . . . . 136

Cross-Training for Treatment and Corrections Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Relationships With the Medical and Psychiatric Staffs. . . . . . . . . . . . . . . . . . . . . . . . . . . . 140

Evaluating the Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

Contents

iv
PART IV—SUMMARIES OF PROGRAMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

Chapter 8 — Summaries of CSAT Women’s Programs for Offenders. . . . . . . . . . . . . . . . . . . . . . . . . . 145

Prison-based Demonstration Projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

Choices TC Program, Pine Bluff, Arkansas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

Delores J. Baylor Women’s Correctional Institution (WCI)

Village TC Program, Wilmington, Delaware. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

Forever Free Program, California Institution for Women,

Frontera, California . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

Recovery In Focus Program, Salem, Oregon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

Jail-based Demonstration Projects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148

Sisters in Sober Treatment and Empowered Recovery

(SISTER) TC Program, San Francisco, California . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148

Stepping Out TC Project, San Diego, California. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

OPTIONS TC Program, Philadelphia, Pennsylvania . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

Incarcerated Women’s Recovery Program,

Seattle, Washington . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

Women’s Acupuncture and Awareness Center, 

Baltimore, Maryland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

Resource List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

Program Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

Screening and Assessment Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167

Resource Centers on Women’s Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Drug-Related Federal Clearinghouses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

Other Sources of Drug Abuse and Criminal Justice-Related Information. . . . . . . . . . . . . . . . . . . . . . . . 171

Appendix—List of Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

Tables

Chapter 1—Women Offenders and Addiction: Research Finding

Table 1. State Data on Treatment and Reduction in Crime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Table 2. Potential Health and Social Savings From Successful

Treatment of AOD Abuse Among Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Chapter 2—Specific Treatment Approaches for Women Offenders

Table 3. Characteristics of CSAT Demonstration Programs

for Women Offenders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Chapter 3—Systems Planning for a Continuum of Care

Table 4. Linkage Recommendations of the National Task Force

on Correctional Substance Abuse Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Table 5. Defining Drug Courts: The Key Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Contents

v
Contents

vi

Chapter 4—Clinical Issues in Treating Women Offenders

Table 6. CSAT’s Comprehensive Treatment Model for Women–Clinical Issues . . . . . . . . . . . . . . . . . . . . 40

Table 7. Recovery In Focus Inmate-Enforced Sanctions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 

Table 8. Interventions of the CSAT Demonstration Programs

for Women Offenders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Chapter 5–Program Design

Table 9. Matching Substance-Abusing Offender Subgroups

to Treatment Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Chapter 6–Stages in the Treatment/Accountability Continuum of Care

Table 10. Continuum of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Table 11. Components of Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

Table 12. Paths Into Community Treatment From Institutional Programs

for Women Offenders With Chronic, Severe AOD Problems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

Table 13. Selected Approaches for Case Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122

Chapter 7–Critical Issues in Implementing Programs

Table 14. Principles of Effective Treatment With Offenders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

Table 15. Cross-Training Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
O

ver the past two

decades, we have

gained considerable

new knowledge about

women and addiction—about why women become

addicted and how these women

can be helped to overcome their

addiction and the related problems in which addiction is frequently embedded. For many

addicted women offenders, their

substance abuse is coincident

with poverty and multiple psychosocial problems, including

mental illness, a history of trauma and abuse, and involvement

in abusive relationships. Today,

substance-abusing women are

entering the jails and prisons of

our Nation at unprecedented

rates. Yet little research has been

done to demonstrate what works

best to habilitate and heal addicted women offenders in the criminal justice system.

Services for women offenders

are fragmented or absent all

across the country, and funds are

scarce for developing the comprehensive networks of community service that women need.

Yet there is great interest in

improving services for women.

Many new programs to treat

women have been started or are

planned in correctional systems

across the country. Communications, cooperative planning,

the use of peers, volunteers, and

mentors, and other creative

strategies need not be expensive

and can be effective ways to fill

the service gaps. This Guide

describes many such promising

and creative strategies.

In an effort to develop and

assess programming for women

offenders, the Center for Substance Abuse Treatment (CSAT) is

funding a series of treatment programs for women in prisons and

jails. Evaluation results from

these projects are just beginning

to emerge, but already much has

been learned. This report shares

the knowledge being gained

from nine selected women’s programs—four in State prisons and

five in jails or detention centers.

All are serving women who have

severe substance abuse problems, often of long duration.

These programs include longand mid-term residential therapeutic communities (TCs), a

prison 4-hours-per-day treatment program, and two intensive

short-term (2-week) programs

that focus on motivating both

sentenced and pre-sentenced

women into treatment.

This report is intended for professionals from a wide range of

disciplines who work with

women involved in some aspect

of the criminal justice system. The

substance abuse counselors and

treatment professionals who

work in either the community

treatment or corrections fields

come from a variety of backgrounds that may include social

work, psychology, and psychiatry.

Corrections professionals may

include sheriffs, wardens, probation and parole officers, and others. This Guide will also be helpful

for State and community-level

policymakers who plan and fund

substance abuse and corrections

programs.

We hope this information—

coming from the published literature, an expert advisory panel,

the CSAT grant project staffs,

CSAT professional staff, and from

program documents—will offer

helpful guidelines and ideas for

designing promising programs to

help addicted women in the

criminal justice system. Some of

the most promising practices

include:

• Building a treatment approach

that is rooted in an understanding about how women

grow and develop, and about

how these social and developmental factors affect addiction.

• Using sanctions in creative and

reasonable ways that will reinforce treatment goals and

engage women in treatment

for the necessary length of

time. 

vii

Foreword
• Assessing each woman’s needs

in a comprehensive, yet flexible, manner so that needs are

matched to the intensity and

length of care required.

• Providing continuity of care,

from the pre-sentencing period

through in-custody treatment

to continuing treatment and

support during the months following release, so that women

have an opportunity to develop

the skills and resources to survive and contribute to their

communities.

• Ensuring that women receive

the housing and other services

that they need so desperately

in the early post-release period, to help them avoid both

relapse and recidivism.

As a final note, this report is

not intended to be a complete

guide or handbook for setting up

new programs. It is instead

intended to offer women-specific

concepts and strategies—a planning framework—for those in

the corrections and treatment

fields who want to design comprehensive services for women

offenders. The resources listed

may assist planners to identify

more in-depth information.

Foreword

viii

Nelba Chavez, Ph.D.

Administrator

Substance Abuse and Mental Health Services Administration

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM

Director

Center for Substance Abuse Treatment 
Advisory Panel Members

ix

T

he Center for Substance Abuse Treatment acknowledges with gratitude the help and assistance

provided by the Advisory Panel. The panel participated in a 1-day meeting to provide initial

guidance on the development of this document, and then reviewed the draft Guide, making many

helpful additions and suggestions.

Gwen Empson

Program Director

WCI Village

New Castle, Delaware

Matonia L. Harris

Treatment Manager

Sister Project-Walden House, Inc.

Sister Project/Sheriff’s Department

San Francisco, California 

Maxine Harris, Ph.D.

Co-Director

Community Correction

Washington, D.C. 

Mary E. McCaul, Ph.D.

Comprehensive Women’s Center

Baltimore, Maryland

Anne McDiarmid

Dakota County Community Corrections

Hastings, Minnesota

Elizabeth Peyton

Director

Treatment Access Center

Wilmington, Delaware

Bonita Veysey, Ph.D.

Women’s Program Director

The National GAINS Center

Delmar, New York
Part I

Setting the Stage

for Treatment

H

ow best to treat

women in our prisons

and jails is a new and

significant concern for

U.S. policymakers. The

number of women incarcerated

in the United States—once a

minuscule number—tripled in

the 1980s alone. In the 15 years

from 1980 to mid-1995, the number of women incarcerated in

U.S. prisons rose by 460 percent,

compared to an increase of 241

percent for men (BJS 1995b). The

same pattern appears with the

jail population. More than three

times as many women were in

jail in mid-1997 as in mid-1985

(BJS 1998a). On average, the

number of women in jail has

grown by 10 percent each year

from mid-1985 to 1997 (BJS

1998a). These figures represent

high present and future costs for

these women—both in terms of

separation from their families

and children and in their inability to contribute economically to

U.S. society.

Most of the women entering

our criminal justice system are

young—under 40 years old—and

8 of every 10 are parents. New

findings show that up to 80 percent of the women offenders in

some State prison systems now

have severe, long-standing substance abuse problems. In 1986,

Congress significantly increased

the penalties associated with

crack cocaine. With the setting of

mandatory minimum sentences

and “three strikes and you’re

out” laws, many women are now

being incarcerated who would

previously have remained in

their communities under criminal justice supervision.

Many of these women are

arrested for drug offenses and

crimes committed to support

their drug habits, in particular

theft and prostitution. The drugdependent women being drawn

into U.S. jails and prisons suffer

from the multiple risk factors that

complicate substance abuse in

women—factors of poverty, psychosocial problems, mental illness, histories of trauma and

abuse, and involvement in abusive relationships. Many were

sexually abused as children.

Approach of the

Center for

Substance Abuse

Treatment 

The Center for Substance Abuse

Treatment (CSAT) is convinced

that these addicted women can

be helped through comprehensive programs designed specifically for women, treating the factors associated with women’s

substance abuse. Evidence shows

that effective treatment programming does empower these

addicted women offenders to

overcome their substance abuse,

to lead a crime-free life, and to

become productive citizens.

Effective women-centered treatment—whether in a prison or

community setting—benefits a

woman and her children and

represents a small investment

but enormous savings for U.S.

society. It costs considerably less

to treat a woman than to build a

jail cell to incarcerate her or to

pay for a foster care placement

for her child. Treatment is likely

to offer long-term positive outcomes for the woman, reducing

both her addiction and her criminal activity. 

CSAT supports the concept that

drug-dependent women should

have access to—and be strongly

encouraged to receive—comprehensive drug abuse treatment.

That treatment should be available in the most appropriate location for the woman, whether that

location is in prison, jail, or in a

community setting with ongoing

supervision. Whenever possible,

treatment should be provided in

the community, so that the

woman’s family can remain intact

3

Chapter 1—Women Offenders and

Addiction: Research Findings
and the woman has the chance to

become sober and drug-free

under real-life conditions.

CSAT is supporting a number

of women’s programs in prisons

and jails, as well as community

corrections treatment networks,

based on this comprehensive

approach to treating women.

CSAT encourages all correctional

systems, in States and local communities, to adopt this comprehensive approach for women in

their jurisdictions. CSAT believes

the following reasons are compelling.

Reason 1: Substance abuse is

driving the explosion of incarcerated women into prisons

and jails.

Women offenders have traditionally represented a small proportion of the total offender population. But over the past decade, the

number of incarcerated women

has dramatically increased, expanding at rates far higher than for

males. The number of women in

jails rose from 15,900 in 1983 to

51,600 in 1996—a 9.5 percent

increase per year; women now

account for more than 10 percent

of the inmates in U.S. jails (BJS

1998b). 

This surge of women into jails

and prisons has been correlated

with the legal system’s increasingly punitive response to drugrelated behavior, and with the

lack of viable treatment and alternative community sanctions for

women (Owen and Bloom 1995).

Even with the large increase in

incarcerated women, the total

number of women prisoners is

not large compared to men. The

numbers of incarcerated women

total more than 78,000 in prison

and 59,000 in jail (BJS 1998a). 

According to Drug Use

Forecasting (DUF) data, more

than half of women in 20 of 21

cities test positive for illicit drugs

at the time of their arrests. The

most common drug used by

women is cocaine. In 12 cities,

more than three-quarters of

women arrestees test positive for

illicit drugs (NIJ 1997) and, in

most cities, a higher percentage

of women than men test positive

for multiple drugs. Recent State

studies show very high percentages of woman offenders who

have drug problems or are in the

criminal justice system for crimes

related to their substance abuse.

• In Massachusetts, the Massachusetts Committee on Criminal

Justice estimated that 90 percent

of women prisoners in 1993 had

alcohol or drug problems.

• In New Jersey, 85 percent of

women offenders are in the correctional system for drug-related offenses—78 percent for

drug-related crimes and an

additional 7 percent for selling

drugs for profit (Gonzalez

1996).

• In Iowa, 61 percent of the

female prison population is

incarcerated for an offense

directly related to substance

abuse (Hudik 1994).

Minority women are being disproportionately affected. The increasing incarceration of women

offenders has had a particularly

grave impact on poor women of

color. By 1994, the proportion of

African American females incarcerated in the United States was

seven times higher than for

white females. The rising use of

crack cocaine among minority

women in poverty appears to be

a major factor. During the last

decade, the number of African

American inmates in State,

Federal, and local jails and prisons has grown at a faster pace

than for non-minority inmates.

The number of black (nonHispanic) women incarcerated

for drug offenses in State prisons

increased by 828 percent from

1986 to 1991 (Mauer and Huling

1995). 

Without treatment, incarceration becomes a “revolving door”

for substance-abusing women.

Addicted women offenders need

substance abuse treatment in

order to begin their recovery

process and then to maintain

abstinence. Addicted women

who have not received appropriate treatment end up back on

drugs and incarcerated because

they are unable to stay “clean”

(drug-free) and sober. These

women then cannot meet the

terms of their probation or they

commit new crimes to support

their habits.

Probation violators are a rapidly growing segment of the prison

population. In Delaware in 1993,

probation violators made up 23

percent of all prison admissions.

Chapter 1—Women Offenders and Addiction: Research Findings

4

The increasing incarceration of women offenders

has had a particularly grave impact on

poor women of color.
Based on standardized screening

criteria, more than 70 percent of

these violators were found to

need residential substance abuse

treatment—the most intensive

level of treatment (Peyton 1994).

Among New Jersey women

offenders, 63 percent of those

incarcerated for violating probation had been imprisoned originally for a drug offense. 

Reason 2: Substance-abusing

women involved with the criminal justice system have alcohol and other drug (AOD)

problems that are severe and

chronic. 

Several measures show that

women offenders are more likely

than male offenders to use drugs,

they use more serious drugs than

male offenders, and they use

them more frequently. Women

are more likely than men to be

under the influence of drugs at

the time of their crimes (Bureau

of Justice Statistics [BJS] 1992;

National Institute of Justice [NIJ]

1991, NIJ 1997).

A number of States are now

using standardized instruments

to screen all offenders in their

correctional systems for AOD

problems. These assessments

show that the substance abuse

problems of incarcerated women

are chronic and severe, indicating the need for comprehensive,

intensive treatment. Examples of

State findings include:

• Delaware: Among incarcerated

women in prison, 26 percent

meet the screening criteria for

long-term residential treatment

(compared to 12 percent of

men). An additional 44 percent

of women meet the criteria for

short-term residential treatment, and 7 percent need

intensive outpatient treatment.

Only 9 percent of Delaware’s

incarcerated women need no

treatment (Peyton 1994, p.12).

• Illinois: Among women

inmates who report a dependence on any drug within the

prior year, 86 percent meet

screening criteria for residential rehabilitation (a severe

level of dependency), 11 percent need intensive outpatient

treatment (a moderate level of

dependency), and 3 percent

require outpatient treatment

for a mild level of dependency

(Illinois Criminal Justice State

Plan 1995).

The Illinois Department of

Corrections finds that women

enter prison at a more advanced

and severe stage of drug abuse

than men. Addicted women

offenders therefore need longer

treatment. Women who stay in

Illinois’ in-custody treatment

program for at least 90 days are

less likely to recidivate than those

in treatment for shorter times.

Further, women who complete

the treatment program are even

less likely to recidivate (Illinois

Criminal Justice State Plan 1995,

p. E-4). These Illinois findings

underscore the importance for

programs to motivate women

into treatment. Women often

“self-select” their length of stay in

treatment, since treatment is generally voluntary. Women who

drop out can be assumed to be

less motivated to change their

behavior than the women who

stay.

Reason 3: Women offenders

suffer from a constellation of

high-risk factors associated

with both substance abuse

and relapse.

Women prisoners in the United

States have many similar characteristics across the country,

according to national surveys

conducted by the Bureau of

Justice Statistics (BJS 1992, 1994,

1995a) and the American

Correctional Association (ACA

1990). For the high proportion of

women with severe substance

abuse problems, substance abuse

complicates and exacerbates

other problem areas, such as family problems, lack of economic

self-sufficiency, physical and sexual abuse, and the inability to

cope with caring for children. To

help women recover and prevent

relapse, treatment needs to help

women address all these issues.

The women experience a host of

psychosocial and medical problems, including physical and sexual abuse and victimization. Imprisoned women come mainly

from poverty. Female prisoners

have very low incomes, are disproportionately from minority

groups, such as African American

and Hispanic, tend to be undereducated and unskilled, and

Chapter 1—Women Offenders and Addiction: Research Findings

5

... women enter prison at a more advanced and

severe stage of drug abuse than men.
have sporadic employment histories. Imprisoned women are

mostly young, single heads of

households. More than threequarters of all women in prison

have children, and two-thirds of

the women have children under

the age of 18 (BJS 1994). Women

prisoners also have a host of

medical, psychological, and

financial problems and needs

(Owen and Bloom 1995).

Mental health problems are

common. Among women in jail

nationally, more than one in

three inmates reports having

received treatment for a mental

or emotional problem other than

drug or alcohol abuse. Approximately 1 in 4 female inmates has

received counseling, 1 in 4 has

taken medication prescribed for

mental or emotional problems,

and 3 in 20 women have been

admitted to a mental health facility and stayed at least overnight

(BJS 1998b).

More than 80 percent of female

jail detainees suffer from one or

more lifetime psychiatric disorders, according to a random

study of nearly 1,300 detainees

awaiting trial at the Cook County

jail (Teplin et al. 1996). This study,

one of the first to survey mental

health problems of women

inmates, found that major depression and substance abuse

were the most common problems. More than 70 percent of

those surveyed were dependent

on drugs or alcohol or both. In

addition, one-third (34 percent)

were suffering from post-traumatic stress disorder (PTSD)—a

common aftermath of physical

and sexual abuse or rape. The

rates of PTSD did not vary by

age, race, or education. Almost

one-fifth (17 percent) had experienced a major depressive episode, with 14 percent having a

depressive episode in the 6

months before arrest.

Bleak as these figures are, the

researchers felt they may be low

because of underreporting of

drug abuse, their inability to

interview some severely disturbed women, and the fact that

some women found their traumatic event(s) too upsetting to

discuss (Teplin et al. 1996). The

researchers point out that, in

practice, few jails currently have

the budget to treat the mental

disorders of the growing female

population. In this Chicago

study, 80 percent of the women

with major depressive episode

and 41 percent of those with

drug and alcohol abuse/dependence were arrested on nonviolent

misdemeanor charges. These

women, as well as nonviolent

felons, could be treated outside

the jail after pretrial hearings, if a

community-based program were

available to treat released jail

detainees, with their often complicated diagnostic profiles and

special treatment needs (Abram

and Teplin 1991; Teplin 1984). 

Similar findings emerged in

the Women Inmates’ Health

Survey (WIHS), the first largescale epidemiologic study of

women prison inmates in the

United States, which was conducted by the Research Triangle

Institute. Using DSM-III-R criteria, the WIHS interviewed virtually all of the 805 women felons

entering North Carolina prisons

over a 17-month period. Compared with women in community epidemiology studies, the

women inmates had high rates of

substance abuse and dependence, of antisocial and borderline

personality disorders, and somewhat higher rates for mood disorders. The highest lifetime

prevalence rates were for drug

abuse and dependence (44 percent), alcohol abuse and dependence (39 percent) and major

depressive episode (13 percent)

(Jordan et al. 1996). Only 11 percent of the women were incarcerated for a violent offense.

Inmate profiles show multiple

problems. A profile of the typical

woman prisoner, compiled by the

New Jersey Department of

Corrections, highlights the intensity of the problems these

women face (Gonzalez 1996). The

profile is based on screening of

all women offenders with the

Addiction Severity Index (ASI)—

a widely used, validated instrument for assessing addiction and

associated problems. In New

Jersey (where 85 percent of

women offenders are incarcerated for an offense related to their

drug use), the typical woman

offender: 

• Is approximately 30 years old

and is incarcerated for a drugrelated crime or selling drugs

for profit.

• Spends approximately $1,000

per week to support her addiction. She has been addicted an

average of 9 years. She is likely

to have used cocaine or heroin

on a daily basis (70 percent of

those using drugs report daily

use, with 23 percent using

drugs more than three times a

day). The typical woman

offender also uses alcohol in

conjunction with other drugs.

• Has worked at primarily

unskilled or semiskilled labor

Chapter 1—Women Offenders and Addiction: Research Findings

6
for minimal wages. When

working, she has not exceeded

24 months of consistent employment at any one job.

• Failed to complete high school

or complete any type of technical trades education.

• Is a single head of household

with minor, dependent children.

• Has experienced emotional,

physical, or sexual abuse.

• Is likely to have grown up in a

home with an alcohol- or drugabusing adult (43 percent lived

with an alcoholic relative and

45 percent lived with a drugabusing relative).

Reason 4: Women offenders

require specialized, womenspecific substance abuse

treatment. 

Women offenders need specialized treatment for their substance dependency. Traditional

substance abuse treatment models were originally designed for

men; they address alcohol and

drug addiction from a male perspective. Women’s substance

abuse is different. Addiction

tends to occur more rapidly for

women than for men, to involve

more than one mood-altering

substance, and to produce serious medical consequences over a

briefer period of time. Women

are more likely than men to have

co-morbid psychiatric disorders.

Typically, women offenders

with substance abuse problems

have been victims of violence—

physical abuse, domestic violence, and rape. On the basis of

compiled studies, Mondanaro et

al. (1982) conclude that 46 percent of all drug-dependent

women have been victims of rape

and from 28 to 44 percent have

been victims of incest. Evidence

suggests that these figures are

even higher among incarcerated

women. For example, a study in

California prisons showed that

nearly 80 percent of women

inmates have experienced some

form of abuse, including:

• Physical abuse: 29 percent

report being physically abused as

children and 60 percent as adults

• Sexual abuse: 31 percent report

being sexually abused as a child,

including incest, and 23 percent

as adults

• Emotional abuse: 40 percent

report emotional abuse as a child

and 48 percent as an adult

(Bloom et al. 1994).

The psychological impact of

this violence includes depression,

post-traumatic stress disorder,

and low self-esteem. The study of

pretrial detainees in Chicago’s

Cook County jail showed that

one-third, a “striking” percent,

had post-traumatic stress disorder (PTSD)—with most of these

women being the victims of rape

or other violent assault (Teplin et

al. 1996). In the study of convicted female felons entering prison

in North Carolina, 30 percent of

the women reported having

experienced both a traumatic

event and six or more PTSD

symptoms in the past 6 months

(Jordan et al. 1996). The CSAT

prison and jail grantees report

that up to 90 percent of women

in their programs have been

physically or sexually abused,

and that these addicted women

offenders feel powerless and victimized. 

By the mid-1970s, women’s

treatment experts had begun calling for treatment programs

designed to address women-specific issues—those issues directly

related to women’s substance

abuse. Odyssey House—one of

the first treatment centers to offer

programs for addicted women

and their children—described

the situation:

Addicted women—especially those with children—

face a unique set of problems

which in the past have precluded successful treatment

outcomes: a male-model

approach to therapy; programs with inadequate

knowledge, capacity, and

resources to meet the special

needs of women; the chronic

medical and complex psychosocial problems unique

to women; and the pressure

of dependent children

(Kandall 1996, p. 207).

Today’s treatment programs

for women offenders can be designed to address the special

needs of these addicted, impoverished, and undereducated

women. New women-specific

programs are designed to empower the woman and help her

learn to trust and bond with

other women for support. When

Chapter 1—Women Offenders and Addiction: Research Findings

7

Women offenders need specialized treatment

for their substance dependency.
possible, there is an effort to

strengthen the woman’s relationships with her children and to

reunify her family.

The new approaches also help

women offenders develop the

coping and life skills they need to

build a productive and self-sufficient future. These skills extend

to many needed areas—to parenting, controlling anger and

stress, learning to identify personal cues of relapse, and managing a budget. And the programs

try to prepare a woman, through

education, vocational tests, and

nonstereotyped job training, for

a place in the labor market.

Reason 5: Few appropriate

treatment programs for

women now exist within the

criminal justice system.

Nationwide, there is a lack of comprehensive treatment services

available for women offenders.

Programs often accept women

without offering specialized services for them. Relatively few treatment programs are geared to the

special needs of women, fewer still

accept women and their children,

and even fewer treat pregnant

women. Generally, the only services offered by 90 percent of prisons are drug education or mutualhelp groups, such as Alcoholics

Anonymous (AA) or Narcotics

Anonymous (NA). Unfortunately,

these programs by themselves do

not provide the kind of intensive,

comprehensive substance abuse

treatment and medical attention

that many women need to overcome addiction.

An American Jail Association

survey in 1992 of 1,737 jails, with

57 percent responding, revealed

that only 28 percent of the

Nation’s jails offer drug abuse

programs for men and women

offenders, including 12-Step volunteer groups; only 19 percent

fund drug treatment programs.

More than 80 percent of programs operate with a volunteer

staff (Peters et al. 1992). A 1989

BJS study of women in jails (BJS

1992) found that

• 42 percent of women reported

daily drug use, but only 11 percent were participating in drug

programming.

• 13 percent of the women are

self-reported alcoholics; 10 percent participated in alcohol

programming. 

Most prison and jail programs

are not intense enough to meet

the needs of women offenders

who have severe and long-term

substance abuse problems. Intensive residential rehabilitation—

the form of treatment needed by

most women offenders—is not

widely available in correctional

settings. In prisons nationwide,

fewer than 9 percent of women

offenders receive residential

treatment (BJS 1994).

There is also a severe deficiency

in comprehensive programming

that includes family unification

and parenting components. In a

survey done by the Office for

Treatment Improvement (OTI) in

1992, one-half of all State facilities

reported a lack of mother/child

programming, including playrooms and residential care.

Another one-third of State facilities reported that their programming in parenting skills, relapse

prevention, and sexuality was

inadequate to meet the demand

for services (OTI 1992).

A study of four California prisons for women showed existing

prison programs are unable to

satisfy the demand for treatment

from their women prisoners.

Programs have long waiting lists

that prevent many women from

participating. Programs that

address parenting or substance

abuse have the longest waiting

lists; up to 450 inmates are waiting to participate in these programs (Bloom et al. 1994).

The number of treatment programs for female drug-abusing

offenders has been increasing.

But because the numbers of

drug-abusing women offenders

keeps rising, the National

Institute of Justice reports that

the increased number of programs has not significantly

reduced the gap between those

needing and receiving services.

In fact, the percentage of drugabusing female offenders being

served, relative to those in need,

is probably no greater than in the

late 1970s (NIJ 1994).

Reason 6: Most women offenders do not receive continuing

care upon release into the

community—a service essential for maintaining recovery

and reducing recidivism.

Continuing care after offenders

return to the community is recognized as one of the most critical

needs for those with substance

abuse problems (ONDCP 1992,

p.71; NIJ 1991). However, a 1992

survey of State prisons found

fewer than one-half of States provide this aftercare for women,

with only one-third arranging for

day treatment, transitional living

services, or residential treatment

in the community. In another survey of 336 women’s programs in

jails and prisons made in 1993,

Prendergast et al. (1995) report

Chapter 1—Women Offenders and Addiction: Research Findings

8
that continued care facilities are

very limited in communities,

serving only a fraction of the

women who require aftercare.

For example, the California

Department of Corrections contracts with only one communitybased program for incarcerated

mothers and their young children. This program has a total

statewide capacity of just 100

women and their children

(Bloom et al. 1994, p.13).

Fewer than half of both jail and

prison programs report that they

make arrangements for transition

services other than substance

abuse treatment (Prendergast et

al. 1995). These other needed

transition services would include

safe and sober housing, financial

assistance, medical care, and case

management. 

Reason 7: Substance abuse

treatment, especially a continuum of care, is effective in

reducing AOD abuse and

recidivism.

A large body of research

demonstrates that treatment of

their substance abuse reduces

offenders’ use of drugs and alcohol, and also reduces their recidivism. Women who relapse are

about seven times as likely to

have a new arrest as those who

do not use drugs during the postrelease period (Martin and

Scarpitti 1993).

The Drug Abuse Treatment

Outcome Study (DATOS), the

most recent comprehensive

national study on the effectiveness of community-based drug

treatment in the United States,

corroborates the findings of earlier large-scale research studies.

These studies are the Drug Abuse

Reporting Program (DARP),

which examined outcomes for

clients entering treatment in

1969-74, and the Treatment

Outcome Prospective Study

(TOPS), which examined outcomes for clients treated in 1979-

81. All three studies—DARP,

TOPS, and DATOS—demonstrate that drug treatment works

to produce positive changes in

both drug use and criminal activity (Simpson 1984; Hubbard et al.

1989; Hubbard et al. 1997).

DATOS assesses the outcomes

of clients treated during 1991-

1993 in 96 community-based

treatment programs in 11 major

cities. The DATOS study followed

up 3,000 randomly selected

clients at 1 year after treatment.

These clients, treated in four different treatment modalities, all

showed large and significant

improvements; their drug use,

illegal activities, and psychological distress were each reduced on

average about 50 percent

(Hubbard et al. 1997). Clients

improved regardless of the form

of treatment. Findings for clients

(34 percent of whom were

women) in two common treatment modalities were:

• Long-term residential treatment,

with 35 percent of clients

referred by the criminal justice

system. Clients showed a 67

percent drop in the number of

weekly cocaine users, a 53 percent decline in heavy drinkers,

a 61 percent decline in illegal

activity, a drop from 77 to 35

percent in those jailed in the

year before versus after treatment, a decrease in those with

any arrests from 56 to 31 percent, and a decline of 46 percent

in suicidal thinking.

• Outpatient drug-free treatment,

with 42 percent of clients

referred by the criminal justice

system. Clients showed a 57

percent drop in the number of

weekly cocaine users, a 64 percent reduction in weekly marijuana users, a 52 percent

decline in heavy drinkers, a 36

percent decline in illegal activity, a drop from 69 to 25 percent

in those jailed in the year

before versus after treatment, a

decrease in those with any

arrests from 37 to 21 percent,

and a decline of 42 percent in

suicidal thinking (Hubbard et

al. 1997).

As in the other national

research studies, the DATOS

study found that the length of

time clients stayed in treatment

was directly related to improvements in their follow-up outcomes (Hubbard et al. 1997). In

both the residential and outpatient treatment, clients who

stayed in treatment for 3 months

or longer had significantly better

outcomes regarding their drug

use and illegal activity; posttreatment outcomes continued to

Chapter 1—Women Offenders and Addiction: Research Findings

9

... treatment of their substance abuse reduces

offenders’ use of drugs and alcohol,

and also reduces their recidivism.
improve as time in treatment

increased. The study found that

programs varied widely in their

ability to retain patients over

time. Programs achieving longer

treatment retention rates had

better client-counselor relationships, provided a wider range of

services, and showed a higher

rate of client satisfaction with the

program (Simpson et al. 1997).

For incarcerated offenders, the

strongest, most consistent pattern

of success comes when offenders

receive a full continuum of treatment. This continuum starts with

appropriate screening and treatment during custody and is followed by post-release treatment

in the community (Lipton 1995).

For those substance-abusing

women offenders who do not

need to be incarcerated, the continuum would begin after their

screening, when the woman is

assigned to enter either a community residential treatment facility

or an intensive outpatient treatment program combined with

supervision in the community. 

Incarcerated women with

severe substance abuse problems

need intensive residential treatment programs, such as therapeutic communities (TCs). The

effectiveness of prison TCs has

been well documented. There

have been four large-scale

research evaluations of TC programs for offenders, three of

which include women. These

program evaluations all demonstrate the same consistent findings—that prison-based TCs can

produce significant reductions in

recidivism rates among chronic

drug-abusing offenders; successful outcomes continue over time.

Success is related to how long the

offender stays in treatment. For

example, New York’s Stay n’ Out

prison TC was effective in reducing recidivism rates, while prison

counseling groups did not.

Findings were:

• Among women who stayed in

treatment less than 3 months,

79 percent had positive parole

outcomes (compared to 40 percent positive outcomes for

men)

• For women spending 9 to 12

months in treatment, 92 percent had favorable outcomes

on parole (compared to 77 percent for men).

The Forever Free prison treatment program—one of the CSATsupported women’s projects

described in this Guide—found

this same type of pattern regarding continuum/time in treatment.

• Among graduates of the

Forever Free program, more

than two-thirds of those who

voluntarily enter residential

treatment in the community

are successful on parole, compared to half of the graduates

who enter community outpatient or no treatment (Prendergast et al. 1996).

• Of those recommitted to

prison after receiving community treatment, more than twothirds are returned for a technical violation rather than a

new offense, compared to half

of those who did not receive

community residential treatment.

• Women who complete 5

months or more of residential

treatment have better parole

outcomes. The reported use of

drugs in the past year is also

much lower for women in the

residential treatment group

than for others. It is important

to note that these women

could self-select to enter residential treatment after their

release from prison. A

woman’s motivation to change

her behavior is a significant

factor in positive treatment

outcomes. 

Reason 8: Treating women

while in custody benefits the

woman, the institution, and

society.

In-custody substance abuse treatment, including short-term interventions directed at motivating a

woman into treatment, offers

multiple benefits—for the

woman, the correctional facility,

and society. This period represents an opportunity to use “constructive coercion” to motivate a

woman offender into entering

treatment and continuing treatment after her release to the community. Research over 25 years

has shown that the longer addicted offenders stay in treatment,

the better the outcome—both in

terms of reduced recidivism and

substance use (De Leon 1984;

Wexler et al. 1988b; Anglin and

Hser 1990). Those who are

coerced into treatment do at least

as well as voluntary clients—and

sometimes do better—because

the coerced clients tend to remain

longer in treatment than those

who volunteer (De Leon 1988;

Platt et al. 1988; Hubbard et al.

1989; Leukefeld and Tims 1988,

1990). 

The woman offender benefits

from in-custody programs. While

a woman is in prison, there is the

time and opportunity—perhaps

for the first time—for compreChapter 1—Women Offenders and Addiction: Research Findings

10
hensive treatment. In a prison situation, time is one of the few

resources that most inmates have

in abundance. There are no competing demands of children,

work, and neighborhood peer

groups. Intensive programs, such

as residential TCs, present other

new opportunities—to interact

with “recovering addict” role

models, to acquire prosocial values and a positive work ethic,

and to initiate a process of education, training, and understanding

of the addiction cycle (Inciardi et

al. 1994). Many young women,

facing incarceration for the first

time, are humiliated and frightened. This is an ideal opportunity for them to be introduced to

treatment and to the possibility

of help and hope in their lives.

Ethnographic studies of street

addicts, who are heavily involved

in crime to support their habits,

show that this group does not

seek treatment of their own volition (Lipton 1995). The correctional system removes women from

an environment in which they are

using, and from its accompanying

stresses and strains. For many, this

may be the first time in years that

they have been drug free and

thinking clearly. It also gives

many women a respite from a

destructive lifestyle in which they

pay for drugs through prostitution and abuse. Incarceration represents a forced, artificial removal

from a woman’s substance-using

lifestyle. As one program director

put it, “This is a brief window of

opportunity to make significant

contact with a woman—to reach

out and motivate her to seek

help.” 

The correctional system benefits

from treatment programs. Establishing a drug treatment unit can

bring positive benefits to a correctional facility. Substance abuse

treatment programs, especially in

women’s prisons, provide an

opportunity for growth and

rehabilitation for the women.

The programs promote responsible, mature inmate behavior,

increase safety for security staff,

and provide a positive structure

for the offender’s time in custody

and in the community after

release. 

Research shows that treatment

programs have fewer disciplinary infractions and correctional

management problems than

other units. Prison therapeutic

communities (TCs) have been

found to be the most drug-free

and trouble-free sectors of the

institutions in which they are

housed (Hooper et al. 1993).

Infractions of prison rules, as well

as threats of violence, also decline

(Lipton 1995). The CSAT-funded

women’s programs demonstrate

this. In the first 21⁄2 years of operation at the Philadelphia OPTIONS

program, disciplinary reports

went from 10 to 12 per month

down to 0 to 2 per month. In addition, when drug treatment programs and random urinalysis are

introduced to a facility, both drug

use and drug dealing (rampant

in some prisons) decline (Vigdal

and Stadler 1989).

The community benefits from

increased public safety and

decreased crime. The research

shows unequivocally that substance abuse is related to crime.

The cost to society of this crime is

enormous, not only in money but

in the emotional and physical

suffering of victims. Although

women offenders are much less

involved in predatory crime than

their male counterparts, research

suggests that the frequency with

which women commit crimes is

approaching that of men (Anglin

and Hser 1987).

CSAT’s first large-scale national

study of clients in publicly funded treatment programs—the

National Treatment Improvement

Evaluation Study (NTIES)—bolsters the often-repeated finding

that AOD treatment reduces subsequent crime among substanceabusing offenders. Most important, this large-scale study

showed that substance abuse

treatment reduces subsequent

crime on an impressive scale.

Among 1,374 women clients in

this study, preliminary results

demonstrate large decreases in

the clients’ involvement in violent

crime, illicit drug distribution, and

prostitution after both residential

and outpatient treatment (CSAT

1995b). The percentage of clients

involved in prostitution was

reduced from 28 percent before

treatment to 7 percent some 12

months after treatment ended

(CSAT 1995b). The final NTIES

report shows that, before treatment, more than 50 percent of

women clients reported having

been involved in some form of

illegal activity. After treatment,

arrests dropped by 67 percent;

Chapter 1—Women Offenders and Addiction: Research Findings

11

While a woman is in prison, there is the time

and opportunity—perhaps for the first time—

for comprehensive treatment.
there was a decrease of 82 percent in women selling drugs, a

decrease of 88 percent in those

reporting shoplifting, and a

decrease of 89 percent in reports

of “beating someone up” (CSAT

1997a).

Numerous State studies also

show that treatment effectively

reduces the level of crime among

addicted users. A report by the

National Association of State

Alcohol and Drug Abuse

Directors (NASADAD) details

positive results of treatment in

reducing crime among treated

offenders in 13 States (Young

1994). Table 1 shows selected

examples of State outcome data.

Reason 9. Treatment saves

money.

It costs less money to treat a

woman offender for substance

abuse than to incarcerate her.

Effective treatment results in savings to society that outweigh the

costs of treatment by a factor of at

least 4 to 1. These are the costs for

incarcerating and treating a substance-abusing woman:

• Incarceration. It costs from

$20,000 to $30,000 per year to

incarcerate a woman in prison

or in a women’s jail (Lord 1995;

Gray et al. 1995). It costs

$54,209 per bed to build a new

State facility and $78,000 per

bed for Federal facilities (CSAT

1995a, p. 13). California alone,

which now has about 11,500

women prisoners (Department

of Corrections 1998), has had to

build two new State facilities

with more than 3,000 beds for

women (Austin et al. 1992).

• Foster care for children. Foster

care for the child of an incarcerated woman adds $3,600 to

$14,000 a year, excluding

administrative costs, to that

total (Lord 1995; American

Public Welfare Association

1995). 

• In-custody AOD treatment.

Residential treatment programs

can be operated in jails or prisons for about $3,000 to $9,000

per inmate per year in addition

to the costs of incarceration

(Lipton 1995). The program’s

total cost would depend on the

Chapter 1—Women Offenders and Addiction: Research Findings

12

Table 1. State data on treatment and reduction in crime

• Oregon—Follow-up data on the arrest rate of females in the 3

years subsequent to treatment are particularly dramatic for residential and outpatient clients. For women who successfully completed

residential treatment, the rate of subsequent arrest was 23 per

100 clients, a rate three times lower than the subsequent arrest

rate (66 per hundred) of a matched group with untreated AOD

problems. For women who successfully completed outpatient

treatment, the rate of subsequent arrest was 27 per 100 clients,

contrasted with a 66 per 100 rate among a matched group of

untreated clients.

• Ohio—Follow-up data on 668 clients show that 410 clients

remained abstinent 1 year after treatment. For these clients,

there were major declines in criminal behavior and consequences.

Criminal arrests declined by 92 percent and time in jail decreased

by 93 percent (Ohio Department of Alcohol and Drug Addiction

Services).

• Texas—Follow-up data on clients who had been arrested in the

12 months before entering treatment showed that, 1 year after

treatment, 70 percent had not been rearrested. Among those who

completed the treatment program, 80 percent were arrest free at

the end of 12 months (Texas Commission on Alcohol and Drug

Abuse).

• California—Clients who had committed any criminal activity

declined from 74 percent before treatment to 20 percent after

treatment. There was a 68 percent drop in selling drugs, a 53 percent drop in exchanging sex for money or drugs, a 62 percent drop

in breaking into a house or vehicle, and a 75 percent drop in use

of a weapon or physical force (California Department of Alcohol

and Drug Programs).

• Minnesota—Among all public and private clients in the State,

36 percent had been arrested during the 6 months before entering

treatment; this decreased to 6 percent in the 6 months after

treatment (Minnesota Chemical Dependency Division).

Source: NASADAD report (Young 1994).
type of program, on the mix of

professional clinical staff and

certified AOD counselors, and

on the size of the caseload.

• TC treatment. Therapeutic

communities, the most intensive form of in-custody treatment, can be provided at reasonable cost. In Illinois, a 250-

bed TC housed within a medium security prison costs

approximately $790,000 annually, or about $3,200 per inmate

per year (CSAT 1995a). These

costs include a process and

outcome evaluation and postrelease case management. No

capital costs associated with

program startup, incarceration,

or security are included.

Most of the CSAT-supported

prison and jail programs

described in this Guide are midto long-term TCs. CSAT’s experience reinforces the finding that

TCs in the criminal justice system

can be operated at quite reasonable cost. Housing, program facilities, and security are provided

by the institution. Among the

CSAT-supported women’s programs, the daily cost per inmate

for incarceration averaged $51.

The average cost of treatment per

day for each woman was $9.22.

For individual TCs, the range in

cost was as follows:

• Daily cost per client for incarceration: $50 to $75

• Daily cost per client for treatment: $9 to $18.27 (CSAT 1998)

Treatment in community settings is less expensive than the

combined cost of incarceration

and treatment. Approximate

treatment costs in the community would include:

• Residential AOD treatment in

the community. Residential

drug treatment for a woman in

the community will cost from

$17,000 to $20,000 per year. 

• Outpatient treatment in the

community. Outpatient treatment costs about $2,700 per

year. For the women addressed

in this Guide—offenders with

chronic, severe substance abuse

problems—outpatient treatment after release from custody

should also be combined with

safe, sober housing and a graduated system of urine monitoring, supervision, and social

services. 

Successful AOD treatment of

offenders creates cost savings to

society. What does treatment

mean in terms of dollars saved to

society? One overview of AOD

treatment for offenders concluded that the savings these programs produce—in costs related

to crime and drug use—pay for

the cost of treatment in about 2 to

3 years (Lipton 1995).

The President’s Commission

on Model State Drug Laws

(1993), in an extensive review of

the socioeconomic benefits of

addictions treatment, concluded

that 

... given the very high risk

behavior of many narcotics

addicts with criminal justice

involvement, and given also

the ability of quality treatment to diminish [intravenous] (IV) drug use and its

attendant risks for HIV transmission, it is almost certain

that the total benefits to society, estimated to be in ratios

as high as 4:1, are seriously

underestimated. When the

potential effects of narcotic

drug use, cocaine addiction,

or HIV positivity on fetuses

carried by pregnant addicts is

factored in, true cost-benefit

analysis (CBA) ratios must be

much higher than even the

positive ones adduced here

(pp. 6-30).

Among more than 4,400 clients

served in CSAT-funded programs, treatment reduced by 59

percent the percentage of those

who had sex for drugs or money

and reduced by 54 percent the

percentage of those who had sex

with an IV drug user (CSAT

1997). A few States have begun to

calculate the savings for their citizens of treating substance

abusers. Following are three

examples.

• California—Taxpayers save

$7.14 in future costs for every

dollar invested in treatment.

Most of these savings come

from reductions in crime. The

cost of treating approximately

150,000 clients was $209 million. The benefit to California

taxpayers, in the first year after

treatment, was approximately

$1.5 billion (National Opinion

Research Center and LewinVHI, Inc. 1994).

• Minnesota—Annual savings

from treating 18,400 clients

total $39.2 million; $8 million of

this is the savings from

reduced arrests, excluding

DWI arrests (Turnure 1995).

• Oregon—The State justice system is estimated to save

approximately $14 million per

year from the fewer arrests,

convictions, and incarcerations

resulting from completed AOD

treatment. In the 3 years subsequent to treatment, only 6 percent of clients who complete

treatment are incarcerated in

the State prison system, compared to 12 percent who terminate without completion. At an

average of $50 per day for

Chapter 1—Women Offenders and Addiction: Research Findings

13
incarceration, treatment saves

an estimated $59,300 per 100

clients who successfully complete treatment. When theft

and victim costs are included,

the total savings for Oregon

reach $32.2 million per year

(Finigan 1995).

Treatment saves money in

health and social costs. When

women offenders go untreated

for their addiction, society also

pays a heavy cost in health and

social damage. These are young

women, likely to become pregnant, many of whom pay for

their drugs through high-risk

sexual behavior. More women

than men in correctional settings

now test positive for the human

immunodeficiency virus (HIV)

(Vlahov 1990). If this lifestyle is

not interrupted, these women

are at risk of HIV not only for

themselves but as a conduit to

their babies and to their sexual

contacts. The lifetime cost of

treating a single HIV-positive

individual suggests what a large

payoff there can be for effectively

treating a substance-abusing

woman offender. Table 2 illustrates the extent of potential

health and social savings when a

woman is effectively treated.

For both male and female

offenders, their untreated addiction exacts a high social cost. With

men, their higher rate of violent

crime creates major costs to society. Substance-abusing women are

responsible for much less social

cost resulting from violent crime

than men are. However, untreated addiction among women

exacts a deep and tragic social

cost. For these women, the costs

are compounded not only by the

health and personal damage to

themselves, but by the serious

and potentially permanent damage that is done to the physical

and emotional health and wellbeing of their children, as well as

the disintegration of their families. Effective treatment for

women offenders is an important

means of building parenting

skills, reuniting families, and

strengthening the potential and

future of the children.

For the children of substanceabusing women, treatment can

often save the costs of providing

foster care, as well as the future

social costs that society may pay

for the emotional damage

endured by these children. As

women drug offenders have been

swelling prison populations, an

increasing number of children are

being cast adrift. When mothers

are incarcerated, only 25 percent

of the children live with their

fathers and the rest go to relatives

or foster care. The National

Council on Crime and Delinquency (NCCD) estimates that on

any single day in 1991, there were

Chapter 1—Women Offenders and Addiction: Research Findings

14

Table 2. Potential health and social savings from

successful treatment of AOD abuse among women

• Preventing new cases of HIV/AIDS: An average lifetime cost for

treating a person with HIV/AIDS is now at least $102,000, up from

$85,000 in 1991 (Hooker and Bryant 1993).

• Preventing fetal alcohol syndrome (FAS): Up to $1,400,000 is

spent on lifetime care costs for each case of FAS (CSAT 1995b,

p. 19).

• Preventing drug-exposed infants: It costs from $48,000 to

$150,000 to treat complications of infants born to addicted

mothers (Health Insurance Association of America 1994). The

costs of caring for a boarder baby,* even if the infant has no

medical complications, range from $200 to $500 per day, or

up to $15,000 per month (CASA 1996).

• Reducing welfare costs: An average of $6,000 per year is saved

for each woman who leaves welfare and gains employment

(Children’s Defense Fund 1995).

• Reducing foster care costs: An average of $3,600 per year is

saved for each child removed from foster care and reunited with

his or her family (American Public Welfare Association 1995)

*Boarder babies are infants under 12 months of age who remain in the hospital past the date of medical charge because parental care is not available.

More than three-fourths of these babies are drug-exposed and over half are of

low birth weight.
approximately 125,000 minor children of women in adult U.S. prisons and jails, a figure that would

now be higher (Bloom and

Steinhart 1993). At a minimum,

loss of the mother causes emotional trauma and anger for children; it can mean lasting emotional damage. The NCCD study

documents the high percentage

of problems among these children, from learning to behavioral

and health problems.

Both States and individual

comprehensive programs for

women report that, as a result of

treatment, women make substantial gains in all the above areas.

Among CSAT-supported comprehensive demonstration programs for pregnant and parenting women, 81 percent of women

referred by the criminal justice

system have no new charges following their treatment (CSAT

1995b). These comprehensive

programs show impressive

results in helping women to be

self- supporting. The following

outcomes and gains have been

reported by several representative programs.

• In California, more than half

the addicted women (55 percent) treated in a residential

demonstration program for

women and their children

were supporting their children—without any help from

AFDC (Aid to Families with

Dependent Children)—within

1 year of completing AOD

treatment (CSAT 1995b).

• In Pennsylvania, the savings

generated by just two CSATsupported treatment programs

for pregnant/parenting women

and their children include:

– $114,000 saved over a 1-year

program from the 46 percent

of participants (19 women)

who became employed.

– $90,000 saved from 26

women being united with

their children over a 1-year

period.

– Potential savings in the millions of dollars from the

delivery of 15 babies who

had no complications due to

substance abuse and no

cases of FAS (Bair 1998).

• In Florida, the 180 women treated in a single residential program have regained custody of

580 children who were previously under State guardianship

(CSAT 1995b).

Chapter 1—Women Offenders and Addiction: Research Findings

15

T

he women’s prison and

jail treatment programs

described in this Guide

reflect a body of new

knowledge and experience about treating women with

drug addictions. By the mid1990s, a great deal of exciting and

promising work was being done

in treating poor and disadvantaged women for substance

abuse, much of it funded

through the Center for Substance

Abuse Treatment (CSAT). Yet little of this new knowledge was

being transferred to programs for

incarcerated women.

Against this background, CSAT

initiated a program to award

grants for innovative demonstration programs in prisons and

jails. The CSAT-funded treatment

programs for women offenders

would be designed to address the

complex needs of this drugdependent, impoverished, and

undereducated population. 

Why Women Need

Specific Treatment

Approaches 

In the 1970s and 1980s, experts

began to look more closely—and

to be concerned—at how women

were faring in the traditional substance abuse treatment programs, which had been designed

for men. Women were badly outnumbered by men in treatment

groups and were not recognized

as having different treatment

needs. Providers began to be

aware that women in coeducational groups tended to focus on

meeting the men’s needs rather

than their own.

Until the mid-1970s, there had

been almost no evaluation and

research done on the outcomes

for women in treatment. When

the research began to tease out

separate findings for women, it

was felt that women were not faring as well as men in these traditional drug and alcohol treatment

programs (Nelson-Zlupko et al.

1995). In that era of nonspecific

programs for women, women

entered treatment at significantly

lower rates than men, and had

lower rates both for being

retained in treatment and for

completing treatment (Beckman

and Amaro 1984; Blume 1990;

Reed 1985; Stevens et al. 1989).

In a movement that has accelerated since the 1970s, treatment

providers began to develop programs for women that incorporate two elements:

• Treating women in all-female

rather than coeducational settings, where the environment

can be more nurturing, supporting, and comfortable for

speaking about such issues as

domestic violence, sexual

abuse and incest, shame, and

self-esteem.

• Addressing the special needs

of women, such as child care,

transportation, and parenting

skills.

Recently, women’s treatment

experts have been calling for new

treatment models designed

specifically for women. Adding

special services to a male treatment model is not sufficient.

Considerable work has gone into

how to modify the traditional

male treatment models so they fit

the psychological and social

needs of women. Chapter 5 discusses some resources and methods that the CSAT grantees used

for modifying their 12-Step and

TC models for women. 

The experience with using allfemale models to serve disadvantaged women is particularly rich

and varied. Since the 1980s, the

Federal government has funded

well over 100 demonstration

treatment programs for disadvantaged women who have substance abuse problems. Since

1992, the block grant funds

administered by CSAT have

required that States set aside 10

percent of these funds for specialized women’s programs.

17

Chapter 2—Specific Treatment

Approaches for Women Offenders 
Based on their experience, a

number of States, such as New

York and Minnesota, now recommend women-only programs as

the treatment of choice for

women who have a history of

physical and sexual abuse. These

new perspectives are an important tool for helping women

offenders in prison, who have an

overwhelming history of abuse.

The outcomes research on these

all-women treatment programs is

still sparse. Practitioners, however,

see evidence that these programs

work well. One study, which compared women in a female-only

program to women in a coed program, found those in the allwoman program did better after 2

years on several measures: fewer

deaths, less alcohol consumption,

less need for inpatient care due to

relapse, higher job stability, better

relationships with children, and

maintenance of child custody

(Dahlgren and Willander 1989). At

the Betty Ford Center, women in

their female-only program were

found more likely to remain sober

for 12 months than women in

coeducational treatment programs (New Standards, Inc. 1993).

After this evaluation, the Betty

Ford Center discontinued coeducational treatment and moved all

women into the female-only program (CASA 1996).

Overview of CSAT’s

Prison and Jail

Programs for

Women

In 1993, CSAT awarded grants to

seven demonstration programs

to treat drug-dependent women

in prisons and jails. These programs, along with two women’s

jail treatment projects from the

CSAT Target Cities’ program, are

described in this Guide. The four

prison and five jail programs

encompass several types of treatment programs, as shown in

table 3. Most are residential therapeutic communities (TCs), an

intensive type of treatment

designed for those with severe

substance abuse problems. One

is a less intense 6-month program

where women receive treatment

for 4 hours daily and are encouraged to enter community residential treatment after release.

Two are short-term, intensive jail

programs designed to motivate

women offenders into community treatment after their release.

Part III of this document highlights the practical experience—

and the strategies—of these programs. Part IV provides summaries of the programs, along

with a listing of materials

developed by the projects that

may be of interest to others. 

These CSAT prison and jail

treatment grantees represent allwomen programs and are based

on CSAT’s comprehensive model

for treating women. The programs represent a pioneering

effort to introduce the new alternative approaches for treating

women into institutional settings

with a criminal justice population.

Assumptions of the

CSAT Women Offender

Programs

The programs operate from varying basic philosophies about

addiction. In each project, the

designers and staff have grappled with how best to help their

women clients—deciding which

developmental model, which

approach, which strategies to

use. The programs vary radically

in length, from a 2-week intensive pre-sentencing jail program

to an 18-month prison program.

The length of a program sets

obvious practical limits on its

treatment goals. A short-term

pre-sentencing program designed

to motivate women into community treatment cannot deal with

the range of issues or therapeutic

approaches that are possible for a

6-month or 12-month residential

treatment program.

Though they differ in theory

and length, all the CSAT programs have certain core elements

and principles in common. All

are predicated on the principle

that good treatment is designed

to address women-specific

issues and that good treatment

Chapter 2—Specific Treatment Approaches for Women Offenders

18

... a number of States, such as New York and

Minnesota, now recommend women-only programs

as the treatment of choice for women who have a

history of physical and sexual abuse.
Table 3. Characteristics of CSAT Demonstration Programs for Women Offenders

Chapter 2—Specific Treatment Approaches for Women Offenders

19

Program

Forever Free*

California Institution

for Women

Frontera, California

X

6 months

minimum

Choices

Pine Bluff, Arkansas

(Community

Punishment Facility)

X

3–24 months

WCI Village

Wilmington, Delaware

X

6–18 months

Recovery in Focus

Pendleton, Oregon

X

6 months

SISTER Program

San Francisco,

California

X

Average

53 days

Stepping Out

Project

San Diego, California

X

Average

62 days

Incarcerated

Women’s

Recovery Project

North Rehabilitation

Facility

Seattle, Washington

X

Up to 12 weeks

Average 14–17

days

Women’s

Acupuncture and

Awareness Center

City Detention Center

Baltimore, Maryland

X

2 weeks

OPTIONS

County Jail System

Philadelphia,

Pennsylvania

X

Average

6 months

Residential

Residential

TC

(Mid/long-term)

Prison programs

Residential

TC

(Mid/short-term)

Intensive

Intervention

Jail programs

*Clients in the Forever Free program live together but co-mingle

with the general prison population during their work assignments.
Chapter 2—Specific Treatment Approaches for Women Offenders

20

programming for women

addresses issues directly related

to their substance abuse behavior. Their basic approach is to

build a treatment program for

women offenders that directly

addresses the clinical issues

affecting women’s abuse and

relapse. These clinical issues are

discussed in chapter 4.

Women-centered, women-specific programs are built on certain

assumptions about treatment

that can differ fundamentally

from programs designed for

men. Developing an effective

program for women in prisons or

jails requires a theoretical approach to addiction treatment

that is sensitive to women and to

the realities of their lives. Such a

theoretical approach needs to

include three components: (1) a

theory of addiction; (2) a theory

of women’s psychological development, especially of how

women learn, grow, and heal;

and (3) a theory of trauma, since

the majority of drug-dependent

women offenders have experienced physical, sexual, and emotional abuse as children and/or as

adults (Covington, in press).

Assumptions About Addiction

In the past, the most common

treatment model of addiction has

been the medical model, which

views addiction as a disease.

Traditionally, addiction has been

compared to diabetes. Both are

chronic diseases; to maintain

physical and emotional stability,

both require adherence to a certain lifestyle. This model is effective in making the analogy that

addiction, like diabetes, should

not carry a moral stigma and cannot be managed by will power.

However, the medical model

sees the disease of addiction as

being rooted solely in the individual. Many treatment providers

today see the origins of addiction

in a broader, more complex context. Some people have a strong

genetic predisposition to addiction. Other addicted people,

including many in the offender

population, have simply grown

up in an environment in which

drug dealing and addiction are a

way of life.

Covington (in press) suggests

that addiction as a disease/disorder can be best understood holistically, and that cancer is the most

meaningful analogy. Today,

many health professionals are

revising their overall concept of

disease. The new holistic

approach recognizes not only the

physical aspects of disease, but

also its emotional, psychological,

and spiritual aspects (Northrup

1994). Covington likens addiction

to cancer because both diseases

involve all these dimensions, as

well as being linked to lifestyle

choices and to the environment.

In all the CSAT demonstration

projects described in this Guide,

addiction is dealt with holistically. Not only its physical aspects,

but the emotional, psychological,

spiritual, and lifestyle components are essential topics in treatment. Several of the programs

stress how important the spiritual aspects are for women offenders. Addiction is viewed and

treated as a complex disorder

imbedded in both the individual

and the society.

Assumptions About Women’s

Emotional Development

These CSAT-supported programs

for women offenders also reflect

the new evolving concepts about

women’s psychological development. Traditional developmental

theory is based on a separation/

individuation model. The new

theories of women’s psychological development, generated in

part by the women’s movement,

represent a major shift in thinking about women. In earlier theories, women’s development was

discussed as the opposite of that

for men—with men having the

“active” qualities of being dominant, assertive, and independent,

while women were seen to have

the “weaker” qualities of being

naturally passive, compliant, submissive, and dependent. Current

thinking stresses the enormous

strength and value in the way

women deal with the world, particularly in their focus on relationships as a central organizing

principle for women’s lives.

The new theories about

women and addiction look at

Women-centered, women-specific programs

are built on certain assumptions about

treatment that can differ fundamentally

from programs designed for men.
Chapter 2—Specific Treatment Approaches for Women Offenders

21

how women have been delegated certain more dependent social

roles having to do with emotions,

nurturing, and caregiving. These

are in fact highly valuable roles,

central to a woman’s emotional

development. The woman’s

development hinges on her relationships with others, including

serving and caring for others,

and on her connections with others and feelings. These organizing principles in women’s lives

are a source of great strength, not

a weakness.

One useful model for understanding the importance of relationships in women’s lives and in

the process of their recovery is

called the “Relational Model”

(Covington and Surrey 1997).

The Relational Model, developed

by the Stone Center in Wellesley,

Massachusetts, posits that the

primary motivation for women

throughout life is not separation,

but establishing a strong sense of

connection with others (Covington, in press). In a growth-fostering relationship, a woman

develops a sense of mutuality

that is “creative, energy-releasing, and empowering for all participants,” and is fundamental

to her psychological well-being

(Covington and Surrey 1997). A

woman who has healthy,

growth-fostering relationships

will derive expanded vitality,

empowerment, self-knowledge,

self-worth, and a desire for more

connection. On the other hand, a

woman who is disconnected

from others or is involved in abusive relationships will experience

the opposite—disempowerment,

confusion, and decreased vitality

and self-worth. Disconnection

from others thus provides the

backdrop for addiction.

In terms of the Relational

Model, the way to help addicted

women change, grow, and heal is

to create programs and environments in which women can form

relationships and mutual connections with others. With this

model, women’s treatment programs aim to establish a setting

where the women can experience healthy relationships with

their counselors and each other

(Covington, in press). The programs are designed to encourage

women to come together, learn to

trust each other, to speak about

personal issues, and to form

bonds of relationship. This model

focuses on strengths in women’s

relationships as a means of recovery (CSAT 1994b). 

Assumptions About Trauma 

and Recovery

As detailed in chapter 1, studies

of women in both prison and jail

find high rates of psychological

trauma in these populations

(Teplin et al. 1996; Jordan et al.

1996). This trauma is related to

the elevated rates of substance

abuse and other psychiatric disorders among women inmates.

According to the CSAT demonstration programs, a vast majority of drug-dependent women

offenders have been physically,

sexually, and emotionally abused

for most of their lives. Such abuse

is a primary trigger for relapse

among women (Covington and

Surrey 1997).

Traditional addiction treatment

does not address issues of physical and sexual abuse during the

period of early recovery. The

CSAT demonstration programs

view this history of abuse as a

central issue in the women

offenders’ addiction and recovery; all programs address this

issue. (The strategies used by the

grantees are described in chapters 4 and 6.)

The women’s programs need a

theory of trauma appropriate for

the early stages of recovery. An

important guide is the book

Trauma and Recovery (1992) by

psychiatrist Judith Herman.

Herman writes that

The core experiences of

psychological trauma are

disempowerment and disconnection from others.

Recovery, then, is based

upon the empowerment of

the survivor and the creation

of new connections. Recovery can take place only

within the context of relationships; it cannot occur in

isolation (p. 133).

The way to help addicted women change, grow,

and heal is to create programs and environments

in which women can form relationships

and mutual connections with others.
Chapter 2—Specific Treatment Approaches for Women Offenders

22

She defines the following three

stages in the process of healing

from trauma:

• Stage 1: Safety. Treatment at

this early stage involves

addressing the woman’s concerns about safety in all

domains.

• Stage 2: Remembrance and

mourning. The survivor tells

the story of the trauma and

mourns the old self that the

trauma destroyed.

• Stage 3: Reconnection. The survivor faces the task of creating

a future; she now develops a

new self.

Women who are in early recovery from addiction also need to

focus on safety as their appropriate first stage in treatment

(Covington, in press). If women

are to recover from trauma, then

programs will need to set up a

safe environment in which the

healing process can take place.

Providing such a safe environment within a prison or jail may

not be easy, but it is the essential

environment required for recovery. Dr. Herman lists 12-Step

groups as one example of the type

of groups appropriate for Stage 1

recovery from trauma. Such

groups focus on issues of self-care

in the here and now and provide

a supportive environment of

peers with similar concerns.

Assumptions About the

Treatment Environment in a

Correctional Setting

Unfortunately, prisons and jails

are not set up to provide a safe

and warm environment in which

women offenders are encouraged to come together in trust

and to form bonds of relationship. As Elaine Lord, superintendent of Bedford Hills Correctional Facility for women, points

out (1995):

Work with women involves “bearing witness” so

that they can examine their

life histories in a safe setting

in which they can sort out

the pathways that took

them to prison, come to be

aware of themselves in

terms of those life histories,

and finally accept and

examine their own responsibility for their own actions.

... There is a need to reconnect to other people and

discover once again capacities for trust, autonomy, initiative, competence, identity, and intimacy.

The warden points out that

prisons are not fertile ground for

such work, that the rigidity and

authoritarianism of prisons by

their very nature can be yet

another experience of power and

control as belonging to others,

not to the woman. Prison does

not allow women to experiment

with their own decision-making

but rather reduces them to an

immature state in which most

decisions of consequence are

made for them (Lord 1995).

Therapeutic communities (TCs)

within a jail or prison setting represent one treatment model that

is capable of counteracting this

authoritarianism and powerlessness. The CSAT-supported TCs

aim to set up an environment in

which the women assume

responsibility for their own

actions and can develop a budding sense of personal power. 

Setting up this type of separate

and autonomous environment

within a prison or jail setting—

whether for a TC or other treatment model—requires considerable planning and coordination

within an institution. All the

CSAT prison demonstration projects seem to have worked out a

successful balance between the

rules of the institution based on

security needs and the separate

rules of their treatment program.

Chapter 7 discusses some of

the strategies that these treatment programs used to gain

institutional support.

Approaches of the

CSAT-funded Women’s

Programs

The CSAT women-specific programs view substance abuse as

being intricately intertwined

with all the major facets of a

woman’s life. The substance

abuse cannot be addressed as an

isolated problem. If a woman is

to heal and maintain recovery,

the treatment program must help

her address both her social and

psychological needs. These areas

include the impact of physical

and sexual abuse during childhood, depression, domestic violence, the drug and alcohol abuse

of her partner, relations with her

children, and the guilt, shame,

and low self-esteem and confidence that her life experience has

produced. 

The CSAT demonstration programs use the new “alternative

approaches” that empower the

woman and help her develop selfesteem and a sense of self. These

approaches appreciate the impor-
tance of relationships as a central

principle and source of strength

in women’s lives. Women offenders learn to trust and bond with

other women for support. When

possible, there is an effort to

strengthen the woman’s relationships with her children and to

reunify her family.

The CSAT-supported programs also help women offenders develop the coping and life

skills they need to build a productive and self-sufficient future.

These skills extend to many

needed areas—to parenting, controlling anger and stress, learning

to identify personal cues of

relapse, and managing a budget.

Women have great difficulty

remaining drug free and sober if

they don’t have the ability to

support their families. The longer

programs try to prepare a

woman, through education,

vocational tests, and non-stereotyped job training, for a place in

the labor market. The shorter

term programs try to arrange for

education, jobs or financial support, drug-free housing, and

ongoing peer support for the

women after release. All the programs have worked hard to

develop a continuum of care that

extends into the community after

the woman is released from the

institution. 

All these women-specific programs aim to provide a similar

environment: one that affirms

and empowers women. The

atmosphere is warm, caring, and

supportive. The programs

encourage trust, bonding, and

sharing of feelings among the

women participants. Staff are primarily women. Because the

women offenders have been victimized and abused, staff members are sensitive to the way

issues of power, authority, and

dominance play out between

staff and participants.

The programs encourage

assertiveness, independence, and

autonomy for the women. At the

same time, there is strong

emphasis on taking personal

responsibility for one’s behavior.

Women “call each other out”

with forthright honesty, but this

confrontation is designed to be

positive and helpful. The programs intend to offer real hope

and motivation to women who

often see themselves as hopeless

and unworthy. 

Recommendations

for Treatment

Programs

The CSAT-funded women’s demonstration programs followed

CSAT’s recommendations on

what to include in treatment programs for incarcerated women.

CSAT recommends that all treatment programs for women in the

criminal justice system be built

along the following principles.

First, CSAT recommends that

States and local communities

develop comprehensive treatment programs for substanceabusing women offenders. These

programs should address the

many complicated physical, emotional, and social factors that

affect women’s abuse of substances and their recovery.

Second, the treatment programs in local correctional facilities (jail or prison) need to be part

of a comprehensive continuum

of care that continues after the

woman’s release from custody.

CSAT recommends that services

listed on the next page be provided as essential services for women

with substance abuse dependency problems.

Critical Role of

Corrections

Administrators

Many of the CSAT-funded programs for women described in

this Guide did not begin until

after they received CSAT funding, most in 1993. This accumulated startup experience with a

group of treatment programs,

begun at a range of institutions,

dramatically demonstrates the

important role of corrections

administrators.

A prison or jail is inherently a

more complicated environment

for starting a treatment program

than other settings. The major

mission of the corrections institution is to provide security. Most

prisons and jails are not set up to

provide the type of environment

needed for women’s treatment

programs—an environment that

offers emotional safety and support and the opportunity for

growth, autonomy, and empowerment.

The CSAT programs were all

able to establish viable programs,

balancing the needs and rules of

the institution with the needs of

their AOD treatment programs.

Those programs that have completed outcome evaluations all

showed a positive impact on the

women’s substance abuse and/or

recidivism (see the program summaries in chapter 8).

Chapter 2—Specific Treatment Approaches for Women Offenders

23
Chapter 2—Specific Treatment Approaches for Women Offenders

24

1

Each woman should receive a thorough assessment of her needs that is female-specific and

culturally relevant. Very few instruments

exist that are specific for women or even womenfocused. The important issue is to be aware that the

assessment needs to be comprehensive and to

include domains that are particularly relevant to

women. Appropriate instruments, as womanfocused as possible, should be used to obtain a

complete criminal history; medical history; history

of substance abuse; physical, emotional, and sexual

abuse history; psychological history; and educational level.

2

While the woman is incarcerated, a treatment

team should do an in-depth assessment to

identify the range of her medical, substance

abuse, criminal justice, and psychosocial problems

and develop an individualized treatment plan. That

plan should address all the needs identified in the

assessment, including homelessness. Treatment

services should begin in the institution.

3

Each woman should be tested for HIV/AIDS

and be provided with pre- and post-test counseling as appropriate to State law, regulations, and administrative guidelines. In prison

and jail programs for women, HIV testing should

be available. The women need to be educated

about HIV and encouraged to undergo HIV/AIDS

testing. Counseling should be provided for all

women tested for HIV/AIDS.

4

Medical care should be provided for the

woman through formal arrangements with

community-based health care facilities. This

care should include screening and treatment for

infectious diseases, including sexually transmitted diseases and hepatitis, and immunizations. It

should also include obstetrical and gynecological

care, including prenatal obstetrical services for

pregnant clients.

5

Substance abuse education and counseling,

psychological counseling (where appropriate), and other women-specific and culturally

appropriate therapeutic activities should be provided throughout the continuum of care. Services

should be offered in the context of family and

other interpersonal relationships, including individual, group, and family counseling. Counseling

based on individualized treatment plans should

be provided for women who have experienced

physical, sexual, psychological, and emotional

abuse and trauma. Counseling based on the individualized treatment plan should also be provided for relapse prevention.

6

Family planning counseling should be provided. This needs to include information on prenatal care, birth control options, adoption,

and education on perinatal transmission of HIV.

7

Training in parenting skills should directly

involve the mother-child dyad and, whenever

possible, involve other family members.

Women in treatment should be permitted and

encouraged to participate in programs for their

children, such as Head Start and Parent and Child

Centers that incorporate parent participation.

8

Interagency agreements should be developed

with relevant child welfare agencies to

address the needs of the children whose

mothers are in local correctional facilities and to

help make possible regular visits from children to

the mothers who do not have custody of their

children. 

9

Formal linkages should be established with

community providers for provision of all necessary services. The services should include

basic needs of food, clothing, housing, finances;

assistance in legal matters, family planning, and

vocational/educational needs; transportation;

health care; mental health services; and support

services.

10

Specialized services should be provided

for the children of female offenders.

Children and other family members

should be included in all levels of the service

delivery network—in the continuum of prevention, treatment, and recovery. The program

should provide therapeutic child care and child

development services, including supervision of

children while their mothers are engaged in

treatment and other rehabilitative activities in

the community.

Recommendations
In working through the initial months of program startup,

it was clear that the attitude,

support, and resources made

available by corrections administrators were absolutely crucial

for success. The following are

some of the most critical elements, which are discussed further throughout this Guide. 

Issue 1. The treatment program’s special therapeutic

environment needs to be

understood and supported at

all levels of the institution.

An AOD program is enormously

benefitted when it exists in a

milieu of support—when the

total prison or jail staff understands the rationale and value of

its special environment. Even

when the corrections administration totally endorses a program,

security personnel may not

understand the program’s supportive, warm environment and

consider it “coddling” the

women. The “word-of-mouth”

institutional underground, before

a program has established its own

record, can either greatly help or

can hobble a new program.

Issue 2. Special dormitory/

housing arrangements within

the prison or jail are needed

for women participating in

intensive substance abuse

treatment programs.

Isolating program participants

from the general prison population is a key element for treatment,

and good treatment programs try

to keep their participants and

graduates separated from the general population. This isolation

from other drug-abusing inmates

continues to be important in the

post-release period. All the CSATsupported programs were able to

gain separate facility space for their

programs. However, in one case,

empty program beds began to be

filled with non-program participants, which caused serious problems for programming.

Issue 3. The security personnel for treatment programs

represent a vital component

in the program.

Administrators can be extremely

helpful to programs when they

understand the program needs

regarding security officers. The

security officers play an important

role in maintaining a program’s

tone and they are important in

supporting the program’s therapeutic environment. Treatment

programs say they need a cadre

of willing security officers who

can be consistently assigned to

the program and cross-trained

along with treatment personnel.

Issue 4. Programs need to be

allowed adequate scheduling

time to provide intensive

treatment.

Standardized screening shows

that women offenders in the

CSAT-funded programs have serious, chronic substance abuse

problems. To treat such problems

requires intensive full-time treatment; it is hard work for women.

Prisons often require offenders to

work 8 hours per day. A full work

schedule means that women

offenders must squeeze AOD programming into at most 4 hours

per day when they are exhausted.

In the CSAT programs, several

prisons allowed the women’s

AOD treatment to count toward

their work requirement.

Issue 5. Coordinating the

release of offenders with

treatment needs can be critical.

Treatment programs are designed

with goals and activities that mesh

with the amount of time that

offenders will be incarcerated. The

length of the usual sentence is critical to what type of program is

planned. A jail treatment program

designed to last 3 to 6 months

won’t work if inmates begin to

cycle through in 14-day stretches.

In addition, the planning for individual program participants needs

to occur in such a way that the

women can be released back to the

community—not to the general

population—when they graduate

from the program.

Issue 6. Providing space for

child and family visits is an

important component for

women offender programs.

A comfortable area for children

and families to visit helps women

maintain bonds with their children. Several of the CSAT-supported programs have been able

to offer areas not only for visits,

but for family therapy. The observation of mother/child interactions allows skilled parenting

help to the mothers.

Issue 7. Planning for postrelease treatment services is

vital.

The most critical period for substance-abusing women offenders

is during their transition to the

community. After prison or jail

treatment, women offenders

badly need supervised aftercare.

Correctional administrators can

foster the needed links to these

community aftercare services. In

several of the CSAT-supported

jail programs, community service

providers come into the facility

and pre-plan with the individual

woman for her post-release treatment and other services.

Chapter 2—Specific Treatment Approaches for Women Offenders

25

T

he Center for Substance

Abuse Treatment (CSAT)

believes that women

offenders with drug

dependency problems

require more services than substance abuse treatment alone,

whether that treatment occurs

during incarceration or in the

community. These women need

a range of social services within a

planned continuum of care. Each

woman offender should have a

continuing care plan in place

before she transitions between

and from correctional agencies.

CSAT believes that integrating

a range of substance abuse treatment services into a criminal

justice treatment network will

provide measurable improvements in these systems. Research supports the conclusion

that outcomes for addicted

women offenders will improve

under a coordinated system of

care, as compared to the

women’s receiving episodic

treatment services at different

points in the criminal justice

process. 

CSAT encourages both State

and community-wide planning

for a continuum of care for

women offenders. Coordination

and cooperation need to be set up

across two major systems. One

system consists of State and local

criminal justice agencies, including courts, pretrial services, jails,

probation, prison, and parole

agencies. The second cooperating

system consists of community

treatment providers involved in

the supervision and treatment of

substance-abusing offenders.

Particularly with women, these

systems also need to interact with

a variety of health and social service agencies.

It needs to be recognized that

systems differ. For example, the

Federal prison system uses its own

employees for substance abuse

treatment. Many State prison systems, such as California, use contractors to provide substance

abuse treatment for incarcerated

women. States and communities

also use many different systems

for handling the post-release

supervision and treatment of

women offenders. These differences create a variety of both limitations and opportunities for

developing a systems approach.

This Guide focuses on the practices of CSAT’s demonstration

programs in attempting to develop a continuum of care for

women offenders within their

existing State and local systems.

In most localities, the lack of a

coordinating system is a major

hurdle in trying to provide a continuum of care for these women.

Background to

Collaboration 

For offenders with serious substance abuse problems, single

strategies are not likely to work—

whether that single strategy is an

isolated episode of treatment,

parole and supervision only, or

case management without the

leverage of criminal justice sanctions or inducements to treatment. To interrupt the cycle of

substance abuse, crime, incarceration, release, and re-offense,

offenders need an integrated and

graduated plan that combines

treatment with sanctions, supervision, and support. Strategies

for monitoring and supporting

each offender need to mesh at

every stage across the two fields

of criminal justice and treatment.

And particularly for women, this

continuum of care needs to

encompass a multitude of other

services, from housing to vocational training to strengthening

and reuniting families.

The current environment for

programs wanting to set up this

kind of joint endeavor is quite

encouraging. Over the past

decade, many people in both the

treatment and criminal justice

fields have made concerted efforts

to develop effective partnerships.

The Center for Substance Abuse

27

Chapter 3—Systems Planning

for a Continuum of Care
Treatment has conducted an

extensive review, with follow-up

technical assistance, of treatmentcriminal justice linkages in more

than 40 States. In 1992, only 12

percent of States had significant

linkages between criminal justice

and substance abuse treatment.

By 1995, 100 percent of States had

established links between probation and parole and substance

abuse treatment and were offering pretrial and pre-sentence substance abuse services.

Many States, local communities, and individual professionals

have worked to set up collaborative relationships between their

criminal justice and substance

abuse treatment systems. As one

CSAT-supported project director

put it, “What we have in this

community is a group of collaborators across systems with good

communications. Our case manager communicates back to the

judge, who is very supportive of

a case management model, and

the enforcement people try to

guarantee success for the women

by advocating for social services

and treatment.” 

Advantages of a

Systemic Approach

In designing programs for

women offenders, planners—

both at the State and the local

level—need to assess their specific situations. In some areas, the

most critical need may be to create linkages across systems and

to fill in service gaps. For example, some areas have no residential treatment available for

women and their children or

have no supervised, safe and

sober housing available for

women after their release. There

may be no case management system to support women offenders

who have been released to the

community, whether these

women are in outpatient treatment or not. Women who go

from prison or jail into residential

treatment may have no system of

support after they voluntarily

leave treatment.

Looking for Gaps in

Service Delivery

For women offenders with substance abuse problems, the country

has a fragmented service system.

This makes it critically important

to think systemically about how

to design services—not just how

to provide links from a single

program to the community.

Where are the most glaring gaps

in a community’s continuum of

treatment, social services, and

supports?

Accountability sanctions and

incentives represent another area

where continuity across systems

is important and where a coordinated systems approach will be

more effective than isolated

actions. Accountability sanctions

include a wide range of methods,

such as incarceration, probation,

and home detention. Sanctions

can play a positive role in promoting recovery from addiction.

Treatment itself may be used as

an intermediate sanction or as an

incentive. Offenders, for example, may be mandated to treatment in lieu of incarceration. As

the woman successfully completes successive stages in her

treatment, she can be rewarded

with reduced sanctions and with

incentives, such as home visits.

When a woman relapses, as

evidenced by a drug-positive

urine test, this regression may be

addressed by increasing the

intensity of an offender’s participation in treatment. Alternatively, the relapsing offender may

be subject to a sanction, such as a

short-term jail sentence.

For male offenders, the use of

intermediate sanctions in combination with AOD treatment is

widely recognized and encouraged. An excellent guide on this

topic is CSAT Treatment Improvement Protocol (TIP) No. 12,

Combining Substance Abuse Treatment With Intermediate Sanctions

for Adults in the Criminal Justice

System (CSAT 1994a).

For women offenders, there is

almost no research on the most

promising sanctions to use in

conjunction with treatment.

What is needed are rational,

data-informed, enlightened, purposeful sanctions and sentencing

practices. Treatment programs

report that a system of intermediate sanctions and rewards is

important as a structure for setting a client’s individual behavioral guidelines during treatment

and probation/parole. The tracking of frequent, random, but

mandatory drug testing is useful.

Experts also believe that community-based sanctions for

women, if they were available,

could be used more extensively

in lieu of incarceration (Owen

and Bloom 1995). For women,

community-based sanctions and

alternatives to incarceration,

such as day reporting centers,

would let a woman stay in the

community for mandated treatment. These alternatives would

be less expensive, and often less

Chapter 3—Systems Planning for a Continuum of Care

28
damaging to her family, than

incarceration. We need to expand

these options for women.

One serious problem for

women after their release from

custody is too many and conflicting requirements. Women can

fail at parole if faced with multiple, conflicting sanctions from

different agencies, including

treatment, custody requirements,

work, and probation/parole visits. For example, the child welfare

agency may require actions that

interfere with a woman’s ability

to attend mandated treatment.

A CSAT project for pregnant

women and their infants found

the most effective way to present sanctions to women was as a

natural consequence of their

behaviors. Knowing that certain

behaviors would result in a

referral to child protective services served to place the control

more in the hands of the client.

Thus the case manager’s role

became one of informing rather

than threatening the client

(Laken and Hutchins 1995, p. 9).

Creating Linkages

Across Agencies

Because of the multiple problems

of women offenders—and the

multiple agencies that are

involved in addressing those

problems—drug treatment for

women offenders needs to move

toward a more systems-oriented

approach to service delivery. This

systems-oriented approach needs

to emphasize

• Linkages and coordination

among programs and agencies

• Joint planning and training

• Shared resource allocation

• Continuity of care for clients

throughout the system

A systemic approach requires

both formal and informal linkages among all the organizations—criminal justice agencies,

drug treatment programs, and

health and social service agencies—involved in providing

treatment services to women

offenders with substance abuse

problems. The treatment capacity

of the system, the kinds of programs and services that are available to women, and the nature of

the linkages among the organizations—all will determine the

structure of a given system and

the ability of its organizations

and officials to meet women’s

needs.

How best to integrate and link

agencies and organizations is a

separate topic, beyond the scope

of this Guide. Table 4 lists the linkage recommendations made by

the National Task Force on

Correctional Substance Abuse

Strategies. How to link systems,

especially the criminal justice

and substance abuse systems, is

discussed in depth in two recent

CSAT Treatment Improvement

Protocols (TIPs)—TIP No. 12 on

combining treatment with intermediate sanctions (CSAT 1994b)

and TIP No. 17 on planning treatment for adults in the criminal

justice system (CSAT 1995a).

Meeting System Needs

As more information is shared

about how existing programs

assess and address women’s

needs, it becomes possible to better meet those needs. A system’s

capacity and services can then be

changed on the basis of information, rather than assumptions,

about the unmet needs for treatment of both individual women

and the women offender population in the aggregate. Having a

system in place, instead of isolated programs, offers a mechanism

for solving many current needs.

These include: 

• The need for a uniform screening and placement system, so

that women can be placed consistently in the most appropriate level of care. The Colorado

correctional system, for example, has developed a screening

system that assesses and

matches offenders to a preferred level of treatment and

has also trained counselors

throughout the system in how

to use it. Other State AOD

agencies have adopted standardized patient placement

criteria, such as the criteria

developed by the American

Society of Addiction Medicine

(ASAM). 

These standardized criteria

can then be adapted for

Chapter 3—Systems Planning for a Continuum of Care

29

One serious problem for women after

their release from custody is too many

and conflicting requirements.
women offenders. As one

example, Pennsylvania has

adapted the ASAM Patient

Placement Criteria to include

all levels of care available, and

the Pennsylvania Criteria are

now being modified to address

the special needs of women

and women with children.

• The need for continuity, comprehensiveness, and individual

tracking for each woman

through each phase of her

treatment and accountability

to the criminal justice system.

Some metropolitan areas, particularly, are now developing

centralized intake units (CIUs)

and management information

systems (MISs) that offer the

means for this kind of tracking

by all systems—corrections,

treatment, and social services.

• The need for coordination and

integration of all components of

the criminal justice system with

each other and with community-based treatment. The lack of

an integrated approach is particularly glaring with women.

For example, women with children are likely to be simultaneously involved with a group of

different social service agencies, as well as probation officers; all may treat families in a

different way and can set up

conflicting requirements. This

kind of system can set up conflicting demands that a woman

cannot meet—setting her up

for failure.

• The need for management practices that create a feedback loop,

so that evaluation results can

inform clinical practices and

create a flow of information

between units.

• The need to identify and magnify whatever funding is available. State needs assessments

show that public funding for

community treatment facilities

everywhere in the country is

grossly inadequate to meet

treatment needs. In Delaware,

for example, available community treatment slots are inadequate to meet the needs just for

the offender population alone,

not even counting the rest of

the citizens who have substance abuse problems (Peyton

1994). 

Chapter 3—Systems Planning for a Continuum of Care

30

Table 4. Linkage recommendations of the National Task

Force on Correctional Substance Abuse Strategies

GOAL: Provide linkages to assure effective communication across the

entire correctional system, including community-based agencies, for

transmitting information and coordinating services.

RECOMMENDATIONS:

• Cumulative information should follow the offender from the earliest

impact point throughout the system.

• Relevant assessment and treatment information should be shared

with all substance abuse treatment programs providing service to the

offender.

• Offenders should have continuing care plans prior to transitioning

between and from correctional agencies.

• Formalized agreements should be developed that detail areas of

responsibility, services provided, and mechanisms for information

exchange among State and local agencies in the correctional system

and the treatment community.

• Combined case planning should be accomplished among correctional and treatment agencies when working with the same

substance-abusing offender, when transferring the offender from

one agency to another, or when transferring the offender from one

part of the correctional system to another.

• Ongoing professional forums among correctional representatives

and community treatment providers, especially at the policy-making

level, should be held to address common concerns and issues.

• Cross-training (training across disciplines and agencies) covering a

wide array of treatment techniques, case management issues, and

criminal justice concerns should be conducted on an ongoing basis

for professionals and paraprofessionals working with substanceabusing offenders.

• A management information system, preferably automated, should

be established and used within and across systems to monitor the

delivery of appropriate substance abuse programming to offenders,

collect data for program evaluation, and establish a rationale for

additional interventions and staff.

—Excerpted from National Institute of Justice, Intervening with Substance-Abusing

Offenders: A Framework for Action; The Report of the National Task Force on Correctional

Substance Abuse Strategies, Washington, DC: U.S. Department of Justice, June 1991, pp.

51-57.
A scarcity of funds for publicly

funded community treatment is

likely to be an increasing problem. Women offenders dependent on alcohol and other drugs,

whose numbers are growing,

may be adversely affected in four

important ways:

• National scarcity of womenspecific community programs.

Women offenders need intensive women-specific treatment

programs, including programs

that also serve their children

and families, and these are in

particularly short supply.

There is concern that, as intensive treatment programs are

introduced in prisons, women

will be incarcerated as the only

available option for providing

them with adequate substance

abuse treatment.

• Waiting lists. Waiting lists for

publicly funded community

treatment slots are common

across the country. When

women offenders transition

from a prison or jail treatment

program into the community,

they need immediate admission

to a community treatment program. Being put on a waiting

list for treatment is not acceptable. Institutional treatment

programs report that women

offenders can be lost to treatment if there is even a day’s

delay between release from the

institution and their entry into

a community program.

• Managed care Medicaid plans.

Across the country, many

States are placing their Medicaid patients under managed

care arrangements. There is

concern that managed care

plans, designed to treat acute

problems, will not cover the

type of treatment needed by

women offenders with their

long-term, chronic problems.

Just how the ancillary services,

such as vocational training and

family counseling, will be paid

for under managed care plans

is also not apparent.

• Loss of welfare support. In the

past, many women offenders

returning to the community

have received welfare support

until they are employed. Such

support assists a woman while

she is in community substance

abuse treatment. Under the

recent welfare reform legislation, women convicted of a

drug offense are no longer eligible for welfare support

unless the State makes an

exemption. Most States have

not done so.

An important solution to the

funding dilemma is to set up

treatment funding that follows

women offenders from in-custody treatment into the continuum of care in the community.

More funding for communitybased treatment through the correctional system is one potential

and positive solution. In some

States, treatment funding is now

linked to offenders through the

correctional system. State correctional or community supervision

departments set up contracts

with community substance

abuse, mental health, and vocational agencies to provide services for offenders on probation. For

example, the California legislature has recently allocated funds

so that graduates of the Forever

Free program from all parts of the

State can receive community

treatment after their release from

prison. (Forever Free is one of the

CSAT-funded treatment programs described in this Guide.) 

Types of

Community-based

Systems Models

For planners in either corrections

or treatment, there are now a

number of different models for

setting up an integrated community system. Several of these

models are demonstrations supported by funding from the

Center for Substance Abuse

Treatment (CSAT). Many of

CSAT’s recent initiatives have

been designed to enhance and

support the development of

treatment systems, as opposed to

single points of intervention.

Treatment Accountability

for Safer Communities

(TASC)

TASC, begun during the 1970s by

the Bureau of Justice Assistance,

is now a widely used model for

bridging the gap between criminal justice agencies (courts and

probation) and the treatment

providers. TASC clients remain in

treatment 6 to 7 weeks longer

than other criminal justice

clients, whether referred to residential or outpatient programs

(Lipton 1995). National studies of

TASC in the 1970s showed that

the program was effective in

reducing rearrest rates; only 8

percent of clients in all sites were

known to have been rearrested

for new offenses while in the

program. 

TASC incorporates the philosophies of both the criminal justice

Chapter 3—Systems Planning for a Continuum of Care

31
and substance abuse treatment

systems into its operating principles. This model capitalizes on the

leverage of the criminal justice

system to achieve maximum benefits from treatment for its clients.

TASC provides supervision, but

this is not equivalent to probation

or correctional supervision. TASC

conducts clinical screens and

assessments and provides case

management services, but it is not

a treatment program. However,

some TASC programs do provide

treatment services either directly

or through contracts. Although

TASC can function as a program,

it is perhaps most powerful when

managing offenders who are

moving through complex levels of

criminal processing, supervision,

and sanctioning, while also

receiving multiple treatment

interventions and modalities.

TASC programs now operate

in more than 100 cities throughout the United States, and TASC

is heavily represented in some

States, including Florida, New

York, Ohio, Pennsylvania,

Illinois, Arizona, and Colorado.

Besides being an effective program model, TASC has also

developed a methodology for

integrating the criminal justice

and substance abuse treatment

systems, holding offenders and

both systems accountable by

means of client-specific case

management. The TASC methods can be used by other programs or systems that are

managing substance-involved

offenders, including women.

These methods are essential in

such efforts as developing partnerships between drug courts

and the treatment delivery system and for linking institutionbased treatment services with

community-based supervision,

treatment services, and aftercare.

TASC has particular expertise in

the following service components:

• Screening and assessment

• Drug testing

• Data collection and

management

• Client monitoring

• Case management

• Client advocacy

• Clinical methods

• Relapse prevention

• Staff training

TASC has developed a public

domain management information system with SEARCH, Inc.,

called TASC-MIS. TASC has also

developed a variety of monographs and guidelines, including

a training curricula, manuals for

trainers and participants, and

monographs on urinalysis as part

of a TASC program and on druginvolved female offenders. 

Drug Courts

Drug courts are an important

development in treating the substance-abusing offender. The

National Association of Drug

Court Professionals (NADCP), an

organization formed several

years ago, defines drug treatment courts as “a special court

given the responsibility to handle

cases involving less serious drugusing offenders through a supervision and treatment program.

These programs include frequent

drug testing, judicial and probationary supervision, drug counseling, treatment, educational

opportunities, and the use of

sanctions and incentives.” The

NADCP has developed a set of

key components for drug courts

(see table 5).

Drug courts are reporting cost

savings. For example, the

Multnomah County, Oregon

Department of Community

Corrections estimated that the

Portland drug court would save

almost $300,000 in costs to the

criminal justice system during

one fiscal year. 

There is no universal model for

drug courts, and not all drug

courts are “diversion” models.

The main types involve drug

treatment and expedited case

processing. The involvement of

judges—and the judge’s detailed

knowledge of an offender’s

behavior, from attending treatment to maintaining “clean”

urines to probation reports—is a

significant and new factor in this

approach. From modest beginnings with four or five drug

courts in the early 1990s, there

were now more than 400 drug

courts in the United States supported by a variety of local, State,

Federal, and private funds and

participant fees. The 1994 Crime

Act authorized the U.S. Attorney

General to award and administer

discretionary grant funds for

drug courts. Many drug courts

were started with Justice

Department grants made available from 1996 through 1998. In

addition, CSAT has provided

modest funding and technical

assistance. 

Drug courts appear to offer a

promising approach for managing drug-abusing women offenders. Some drug courts for women

have been developed. One such

example is the Brooklyn, New

York, Treatment Court, which is

supported by CSAT as a project

in the Criminal Justice Networks

demonstration program.

Chapter 3—Systems Planning for a Continuum of Care

32
Three helpful resources are

shown in the box on the following page.

Integrated Management

Information Systems

CSAT, through its Target Cities

initiative, provides discretionary

funding to develop infrastructure planning in major metropolitan areas. Criminal justice

components are now part of

these treatment networks in 11

cities. Two projects described in

this Guide—the Baltimore

Women’s Acupuncture and

Awareness Program and the

OPTIONS program in Philadelphia—are both benefiting

from new comprehensive programs for women made available under this project. The

Target Cities that contain criminal justice components, most of

which are jail-based, include

Albuquerque, Baltimore, Cleveland, Dallas, Detroit, Newark,

New Orleans, Philadelphia,

Portland, San Francisco, and St.

Louis. 

The approach of the CSAT

Target Cities program is to

develop an infrastructure that

will support coordination, communications, and information

sharing across the network. The

projects focus on developing

such integrating mechanisms as

centralized intake units (CIUs)

and management information

systems. 

Community Networks

Late in 1995, CSAT awarded

eight cooperative agreements to

develop and implement a

sophisticated new concept—

criminal justice treatment networks. This demonstration program involves consortia led by a

local court or community corrections agency, which also include

Chapter 3—Systems Planning for a Continuum of Care

33

Table 5. Defining drug courts: The key components

The National Association of Drug Court Professionals

Drug Court Standards Committee

Key Component No. 1: Drug courts integrate alcohol and other drug treatment services with justice

system case processing.

Key Component No. 2: Using a nonadversarial approach, prosecution and defense counsel promote

public safety while protecting participants’ due process rights.

Key Component No. 3: Eligible participants are identified early and promptly placed in the

drug court program.

Key Component No. 4: Drug courts provide access to a continuum of alcohol, drug, and other related treatment and rehabilitation services.

Key Component No. 5: Abstinence is monitored by frequent alcohol and other drug testing.

Key Component No. 6: A coordinated strategy governs drug court responses to participants’ compliance.

Key Component No. 7: Ongoing judicial interaction with each drug court participant is essential.

Key Component No. 8: Monitoring and evaluation measure the achievement of program goals and

gauge effectiveness.

Key Component No. 9: Continuing interdisciplinary education promotes effective drug court planning, implementation, and operations.

Key Component No. 10: Forging partnerships among drug courts, public agencies, and community-based

organizations generates local support and enhances drug court effectiveness.

From: Office of Justice Programs (OJP) Drug Courts Program Office. Defining Drug Courts: The Key Components, by The National Association

of Drug Court Professionals Drug Court Standards Committee. Washington, DC: U.S. Department of Justice, January 1997.
substance abuse treatment agencies and a range of health and

mental health organizations.

Four of the community networks

are specifically designed to serve

women—these are in Brooklyn,

Philadelphia, San Francisco, and

Phoenix.

This holistic approach represents an intensive effort to build

and strengthen networks made

up of diverse organizations and

systems that have conflicting

goals, varied management and

operating philosophies, and differing realities. Each network is

developing an automated management information tracking

system to document the progress

of both programs and individual

offenders. The most effective

models—those that expand services in a cost-effective way and

show enhanced treatment outcomes in reduced drug use,

lower recidivism, and improved

social functioning—will be

appropriate for replication. The

models selected for replication

will include intake screening and

assessment and will provide a

continuum of care that includes

case management, primary

health and mental health care,

and other supportive services.

CSAT’s

Recommended

Approaches for

Establishing

Networks

The goal of an integrated network

is to provide women offenders

with a systemic, unified approach

where all statewide or community

agencies join together to supervise, case manage, and treat

offenders. CSAT expects such collaborative efforts to expand service delivery and reduce the cost of

treatment to criminal justice

clients, as compared with the cost

of current systems that provide

single points of intervention.

A network is defined as a tightly

structured partnership of State

and local government and criminal justice agencies, including

courts, pretrial services, probation/parole, and law enforcement.

Other government agencies include public and nonprofit primary health care, mental health

care, substance abuse treatment,

allied social services, job placement agencies, and schools. At the

local network level, the primary

leadership should come from the

local jurisdiction’s judiciary or

probation/community corrections

agency. The continuum of services needs to be integrated around

some key intake point that can

operate as a “gatekeeper” to the

system. For example, a drug

diversion court or a jail/detention

agency could function as the central intake point. (CSAT’s recommendations follow.) 

Chapter 3—Systems Planning for a Continuum of Care

34

Helpful resources for information about drug courts

• CSAT Treatment Improvement Protocol TIP, No. 23

Center for Substance Abuse Treatment. Treatment Drug Courts:

Integrating Substance Abuse Treatment With Legal Case

Processing. Treatment Improvement Protocol (TIP) Series,

No. 23. DHHS Pub. No. (SMA) 96-3113. Rockville, MD:

Substance Abuse and Mental Health Services

Administration, 1996.

• Briefing report by the U.S. General Accounting Office

U.S. General Accounting Office. Drug Courts: Information on a

New Approach to Address Drug-Related Crime. Briefing 

Report to the Committee on the Judiciary, U.S. Senate,

and the Committee on the Judiciary, House of

Representatives. Washington, DC: General Accounting

Office (GAO/GGD-95-159BR), May 1995.

• Defining Drug Courts: The Key Components, by the

National Association of Drug Court Professionals

Office of Justice Programs (OJP) Drug Courts Program Office.

Defining Drug Courts: The Key Components, by The National

Association of Drug Court Professionals Drug Court

Standards Committee. Washington, DC: U.S. Department

of Justice, January 1997.
1

The local consortium or network needs to

tie together the pivotal points of referral

and supervision in the courts or community

supervision agencies (probation and parole agencies) with the appropriate State and local agencies

responsible for offender treatment services.

2

The services provided through the consortium should include addiction treatment,

public health, primary health care, mental

health services, supervision/testing by courts and

corrections agencies, and child welfare services.

3

The consortium should create a new infrastructure or enhance existing components

for a comprehensive criminal justice network by incorporating and integrating existing

Federal, State, and locally funded projects. The

consortium should identify and work with projects that serve specific target populations

involved with the criminal justice system.

4

The model developed by the consortium

needs to include a centralized intake point

of entry where offenders referred by the

courts and criminal justice system can be comprehensively assessed and referred to treatment. The

model needs to include intake screening, assessment, and the provision of a continuum of care

that includes case management, primary health

and mental health care, and other services for eligible substance-abusing women offenders.

5

The consortium should integrate culturally

sensitive services as appropriate for ethnic

and other minority groups in terms of both

program planning and implementation.

6

A core element of the network services

should be a case management system that

provides appropriate supervision and tracking. This case management is expected to include

assisting clients with referrals, tracking clients, frequent case review, frequently scheduled random

urine testing, a schedule of regular and frequent

communication with community treatment providers, and frequent reporting of client progress

to the referring criminal justice agencies.

7

Case managers may be situated at numerous points within the system. These case

managers should be individuals knowledgeable about the criminal justice process,

offender clients, substance abuse treatment,

and child welfare and other women-specific

services.

8

A system of intermediate sanctions and

positive rewards should be implemented as

a structure for client behavioral guidelines.

9

Comprehensive, women-specific treatment

should be provided for women offenders

with AOD abuse. This treatment should

address the clinical issues related to women’s

substance abuse, including primary and specialty

health care for infectious diseases and other

physical disorders, mental health services, violence reduction and intervention, family counseling and job placement, services for victims of

physical or sexual abuse, and services for families

and children.

10

The public health component of the

treatment regimen should involve local

and/or State agencies that engage in

screening and counseling for infectious diseases,

as well as coordination with treatment providers.

The infectious diseases of concern include

HIV/AIDS, tuberculosis (TB), sexually transmitted

diseases, and hepatitis B.

11

The consortium should develop an

automated management information

system (MIS) for rapid communication

across agencies and to allow for rapid tracking

and referral of clients for maximum system-wide

utilization of treatment capacity. This MIS will be

designed so that it continues to protect client confidentiality.

12

A goal for the system should be to

expand service delivery and increase

access to substance abuse, mental

health, and primary care treatment for women

offenders who need these services. A longer term

goal should be to provide improved treatment

outcomes by means of more effective treatment

and recovery services. These improved outcomes

can be measured through reduced drug usage

and associated problems, lower criminal justice

system recidivism, and improved health and

social functioning.

Chapter 3—Systems Planning for a Continuum of Care

35

Recommendations

Part II

Designing Treatment

Programs

T

he women served in the

CSAT-funded prison and

jail programs all have

severe substance abuse

problems. Many are

dependent on more than one

drug, have a history of substance

abuse extending over a number

of years, and often have already

undergone some substance

abuse treatment.

Although women in both the

prison and jail programs share

serious substance abuse problems,

program managers emphasize that

these are distinct client populations. The CSAT prison demonstration programs stress the overall

severity of their clients’ problems

in three areas—drug addiction,

social and cognitive deficits, and

criminogenic behavior. The severity of these problems must all be

addressed in prison treatment programs. Women in the jail programs

often have a shorter history of

drug problems and of criminal

behavior. 

The characteristics of clients in

two CSAT-supported programs

suggest how prison and jail populations may differ.

• The Forever Free prison program.

In this 6-month treatment program, a typical participant

could have a 25-year daily

heroin addiction, no high

school diploma, no legal job

history, social and cognitive

deficits, and a criminal history

(typically petty theft) going

back 30 years.

• The Baltimore Detention Center

program. This 2-week Baltimore

pre-trial program targets female

substance abusers in the city

detention center—women who

have less extensive histories of

drug use and crime and are

therefore likely to be released

back to the streets at the time of

trial. The majority of women

lack a high school diploma and

have limited work histories.

These women, like those in the

State prison programs, are

heavily involved with drugs. In

the Baltimore program, 74 percent of the women report heroin as their primary substance

problem, more than 80 percent

report a secondary drug problem (most often cocaine), and

40 percent report alcohol

abuse/dependence in addition

to their primary drug problem(s).

For all women offenders with

serious substance abuse problems, the substance abuse cannot

be successfully treated in isolation

from the social and psychological

issues in which their addiction is

embedded. Critical issues to

address—for both recovery and

for public health reasons—are

empowerment/self-esteem, sexual and physical abuse and violence/victimization, and health

and high-risk behaviors. The

Center for Substance Abuse

Treatment (CSAT) required that

their program grantees serving

incarcerated women develop

programs that address the major

clinical issues affecting substanceabusing women. These major

issues are listed in table 6. The following section describes each of

these clinical issues in chronological order, following CSAT’s list.

This list is not intended to suggest

any priority order. All issues are

important. 

Clinical Issues

Affecting Substance

Abuse in Women

Clinical Issue 1: The

etiology of addiction, especially gender-specific issues

Women’s drinking and drug abuse

is different from men’s. Knowledge

about how and why women

become addicted to alcohol and

drugs has been steadily growing

since the 1970s. Current research

indicates that chemically dependent women differ from their male

counterparts in significant ways:

in their patterns of drug use, their

39

Chapter 4—Clinical Issues

in Treating Women Offenders
psychosocial characteristics, and

in the physiological consequences of their drug use

(Nelson-Zlupko et al. 1995). For

example, unlike men, women

often describe the onset of drug

use as sudden and heavy rather

than gradual.

Women are more likely than

men to be addicted to more than

one mood-altering substance,

and many addicted women

report that they began using

drugs after a specific traumatic

event in their lives. Most importantly, for women, chemical

addiction frequently represents

an effort to self-medicate for

depression and other mental

impairments, to numb pain, and

to make tolerable what is a

painful and hopeless life. Women

have higher rates of psychiatric

comorbidity than men.

Women substance abusers

often have experienced physical

and sexual abuse during their

childhood. More than for men,

women’s substance abuse is intertwined with the drug and alcohol

abuse of their partners. To achieve

lasting recovery from substance

abuse, women need to work

through issues of guilt and

shame, lack of self-esteem, and

feelings of disconnection and disempowerment. Substance-abusing women need to build trust,

bonding, and hope as a basis for

recovery.

Women’s addiction is complex

and embedded in psychosocial

and other issues. Many clinical,

developmental, and economic

issues are intertwined as the

framework for substance abuse

in women offenders. The major

issues affecting substance abuse

in women fall into the following

categories:

• Psychological stressors for

women, including sexual and

physical abuse, violence, and

victimization

• Social and cultural role issues

for women, which pertain to

stigma, self-esteem, undereducation, and economic deficits

Chapter 4—Clinical Issues in Treating Women Offenders

40

Table 6. CSAT’s Comprehensive Treatment Model

for Women—Clinical Issues

Within the treatment program, counselors should address the

following issues:

1. The etiology of addiction, especially gender-specific issues related

to addiction (including social, physiological, and psychological

consequences of addiction, as well as factors related to the onset

of addiction)

2. Low self-esteem

3. Race, ethnicity, and cultural issues

4. Gender discrimination and harassment

5. Disability-related issues, where relevant

6. Relationships with family and significant others

7. Attachments to unhealthy interpersonal relationships

8. Interpersonal violence, including incest, rape, battering, and

other abuse

9. Eating disorders

10. Sexuality, including sexual functioning and sexual orientation

11. Parenting

12. Grief related to loss: to the loss of the substance that was being

abused, and the emotional losses related to the woman’s children,

family members, or partner

13. Work

14. Appearance and overall health and hygiene

15. Isolation related to a lack of support systems (which may or may not

include family members and/or partners) and other resources

16. Life plan development

17. Child care and child custody

Source: Practical Approaches in the Treatment of Women Who Abuse Alcohol

and Other Drugs, Center for Substance Abuse Treatment (CSAT), 1994c, 

pp. 178-179.
• Centrality of women’s relationships as an organizing principle in their lives, particularly

their relationships with children and family

• Loss of self-image and personal empowerment 

• Vulnerability in health and

high-risk behaviors, with frequent medical problems and a

high rate of HIV/AIDS and sexually transmitted diseases

Clinical Issue 2: Low selfesteem 

Substance-abusing women lack

self-esteem, regardless of their

socioeconomic level. Addicted

women offenders who serve time

in jail or prison have been reported to have very low self-esteem,

combined with a feeling of

almost total lack of power over

any aspect of their lives.

The CSAT grantees have found

their women clients typically feel

powerless over their lives and

exhibit extremely low self-esteem.

The Forever Free program, in

testing for self-esteem, found that

more than 70 percent of their

women clients fell in the lowest 1

percent on a scale normed for the

general population. As one project director pointed out, these

women have experienced such

powerlessness that they have no

sense of self-efficacy. That is, the

women truly see no cause and

effect relationship between their

actions and the consequences. An

initial step in treatment is to

develop the woman’s consequential thinking—the belief that she

can affect how things happen. 

Programming approaches. New

psychological approaches, called

“alternative approaches,” offer

great promise as a framework for

helping women offenders who

have serious substance abuse

problems. These theories perceive

women to be developing within

the confines of a culturally driven

society, with a “cultural mandate

to be powerless” (see, for example,

Miller 1986). The theorists look at

the impact on women of growing

up in a society whose institutions

were built and designed by and

for men. It is important to understand this “cultural mandate” as

the backdrop to understanding

why women feel powerless and

may resist independence and

autonomy.

The CSAT-funded grantees

point out that women offenders—whose boundaries of self

have been profoundly violated—

need to face the realities of their

situation without being mired in

guilt and shame. These marginalized women need a program that

is designed to help them become

empowered, to build their selfesteem, and to find their inherent

inner strengths.

Programs for incarcerated

women need to provide an

approach that supports and bolsters these women’s very low

self-esteem. The approach needs

to encourage trust, bonding, and

empowerment, and to provide

confrontation that is low key and

supportive. Firm, but supportive,

confrontation is absolutely essential for these women—a theme

that will be stressed throughout

this document.

Rather than being a specific

intervention, the push toward

empowering the women and

developing their self-esteem and

identity are underlying motifs

throughout the entire program.

This is accomplished by the program’s policies and by the many

small gestures that set a program’s tone. For example, as

described in chapter 5 in the section on TC models, the WCI

Village program never asks a

woman to face a difficult issue in

group alone. A buddy is always

beside her and uses either verbal

reinforcement or physical touching to convey support and the

belief that the woman can face

this difficult issue in her life.

Clinical Issue 3: Race, ethnicity, and cultural issues

Many incarcerated women with

substance abuse problems come

from minority racial and ethnic

groups. Race, ethnicity, and culture are all important to a

woman’s sense of identity, to her

life experience, and to her personal history of drug use. The

nuances of these differences

need to be understood and

respected.

For women of color, racism

may be a central issue. Racism is a

very sensitive and often uncomfortable issue to talk about.

Because the topic is so difficult,

racism often is not addressed in

treatment programs. In addition,

women of color can find it very

Chapter 4—Clinical Issues in Treating Women Offenders

41

Substance-abusing women lack self-esteem,

regardless of their socioeconomic level.
difficult to ask for help with such

problems as substance abuse and

mental health issues, because

they do not trust the systems that

have traditionally provided this

care. Incarcerated women of color

especially feel that the criminal

justice system does not treat them

equitably (Kanuha 1994, p. 447).

These women feel that counselors

and clinicians will not understand them, just as those who

were supposed to help them during the judicial process did not.

Every clinician must seriously consider the intense,

historical, and reality-based

conflict that some battered

women of color have about

protecting themselves from

violence vs. protecting their

family or community from

judgment or further stigmatization as a result of

institutionalized racism.

Practitioners must balance

the issue of safety for the

battered victim with the

real and perceived experiences of battered women of

color that the very institutions mandated to help

them, such as the police

and courts, themselves

have a legacy of violence

toward men and women of

color (Kanuha 1994, p. 447).

Because of their own cultural

experience, women of color may

approach certain important issues

from a different perspective than

other groups. For example,

women of color have a harder

time than others in acknowledging abuse by the men in their lives

(Rogers et al., n.d.). These women

often use the excuse that their

men are constantly faced with

racist attitudes; the only place

where the men can express their

anger is at home. In addition,

women of color are also more

reluctant to report abuses against

themselves and their children

than other women may be (White

1986). These women fear the consequences of the criminal justice

system not only for themselves

and for the men of color in their

lives, but for their children as well

(C.F. Newkirk, personal communication, 1997). 

Programming approaches. The

CSAT-sponsored treatment programs for women work to provide

a culturally sensitive environment

and, in many cases, special programming for specific ethnic and

minority groups. As a base, such

programs approach each woman

with respect for her cultural traditions and an understanding that

her acculturation exerts profound

effects on how a woman views

herself and others, on her feelings

and what she values, and on her

behavior. Designing a culturally

sensitive program requires attention to at least the following two

key issues:

• Awareness of the wide differences within ethnic groups. For

example, Hispanic or Latina

women come from a variety of

different countries and cultural

traditions. American Indian

tribes represent a considerable

range of cultural attitudes and

values, with differences pertaining to women’s traditional

roles and power, child-rearing

practices, and many clinical

issues. An excellent overview

of this diversity appears in

Comas-Díaz and Greene

(1994), in a seven-chapter section titled “Women of Color: A

Portrait of Heterogeneity.”

• Awareness of the challenges in

providing a culturally sensitive

staff. It is important to realize

that all staff, regardless of their

ethnicity, may need training in

cultural sensitivity and knowledge. Just because a peer counselor or professional staff member comes from a particular

racial or ethnic group does not

mean that the person will necessarily be sensitive to specific

cultural issues of that group.

Staff members’ life experiences

may have been quite different

from those of the group they

are asked to counsel and treat.

One recommended strategy is

to make the discussion of cultural

differences a part of everyday

conversations in the program,

especially in process groups. This

ongoing attention fosters respect

for differences. Both clients and

staff learn from each other what

their differences and similarities

are. In our society, we have

learned to talk about how

women and men think and act

differently, based on their acculturation. Similar differences

occur as a result of racial and ethnic issues, but as a society we find

these issues difficult to talk

about. 

In substance abuse treatment,

women’s groups are used to

focus on topics affecting special

populations. Several of the CSATsupported programs offer special

counseling and process groups

for culturally specific and older

women’s groups.

Clinical Issue 4: Gender discrimination and harassment

Programs for women need to

acknowledge and explore the

broad-ranging effects on women

Chapter 4—Clinical Issues in Treating Women Offenders

42
of the sexism still encountered in

American society. The differential

treatment of men and women

underlies many of the issues that

women need to address, including self-esteem, roles, and work

opportunities. 

Alcoholic and addicted women

suffer from the social stigma

attached to women’s drinking

and drug use. It is widely recognized that this stigma is greater

for women than for men. The

shame and secrecy that surrounds this addictive behavior is

one challenge. Cultural disapproval and disdain for abusing

women is damaging to the

women’s sense of self. The vehemence of this disapproval can be

seen in recent U.S. social and

legal responses to women’s substance abuse, such as efforts in

some States to imprison substance-abusing women who are

pregnant rather than to treat

them. Substance-abusing women

in prisons and jails must combat

not only the stigma attached to

being a woman with addiction

problems, but also the multidimensional effects of being a

woman—often a single mother—

without education or job skills,

with few or no legal sources of

income, and living in poverty if

not homelessness.

All substance-abusing women

feel the effects of this social stigma

and disapproval. But women in

prison or jail must face this disdain

on all levels. These are typically

poor women, undereducated and

generally without jobs. Many are

women of color. Women generally

have low-ranking roles in maledominated drug-dealing, which

don’t net them much income.

Many of these women are forced

by economic need to support their

drug habits through prostitution

or the barter of sex for small sums

of money. Our society thinks very

badly of such women. Their children have been neglected and in

some cases abused. It is devastating for women to feel they have

failed to be a “good woman” in so

many dimensions. Women often

turn the cultural disdain for this

behavior inward on themselves.

The effect is to erode a woman’s

self-esteem and paralyze her ability to recover and build a different

life.

Women are most often the victims of domestic violence, but

they can also be the perpetrators

of physical and sexual abuse. In

our society, we have a strong

social taboo regarding women

who are perpetrators, particularly when they neglect or abuse

their children. Because of the

stigma, it is very difficult for

clients and for staff, as well, to

discuss these behaviors. Staff

need to be aware and empathic

about the fact that many women

offenders are at risk for these

behaviors because of their histories of physical and sexual abuse,

as well as incest. This experience

of abuse, combined with their

present alcohol and/or other

drug abuse, make these women

offenders particulary vulnerable

to such behaviors and to “acting

out” in terms of their own stigma.

The programming approaches.

Gender discrimination, combined with racism and social stigma, are deep-seated currents in

U.S. society that create guilt,

shame, and lowered self-esteem

for substance-abusing women, as

well as lessening their real opportunities. Their effects on women

need to be recognized within the

program. For example, a womancentered program philosophy

can acknowledge the many ways

in which women in our society

may be economically disadvantaged, financially dependent,

and lacking in marketable job

skills. This perspective lets the

woman offender know she is not

personally deficient because she

is poor and has few job skills.

These are circumstances a

woman can hope to change.

An important strategy is to

provide female role models who

demonstrate competence and

power. Aspects of this include:

• Providing female counseling

staff, including women who

are in recovery from substance

abuse and/or are ex-offenders

themselves (several of the

CSAT-funded programs have

all-female staffs)

• Ensuring that women staff

members have administrative

positions of authority (it is

more common for treatment

programs to have men in the

key administrative and supervisory positions while women

work as counselors)

Chapter 4—Clinical Issues in Treating Women Offenders

43

Programs for women need to acknowledge

and explore the broad-ranging effects on women

of the sexism still encountered in American society. 
• Hiring an ethnically diverse

staff and bringing back successful program graduates of

differing backgrounds to serve

as additional role models

Clinical Issue 5: Relevant disability-related issues

Disabilities place a woman at

increased risk of drug and alcohol abuse. For substance-abusing

women who have disabilities, the

role these disabilities may play in

a woman’s addiction is an important topic to pursue. For this reason, CSAT lists the presence of

disabilities as an important clinical issue in treating women. This

topic needs to be considered and

addressed by anyone designing

and setting up a treatment program. 

However, the women clients in

the CSAT offender demonstration programs did not present

with serious physical disabilities.

Since disability-related issues

were not a concern among the

grantees, the CSAT jail and

prison programs did not develop

any specific program strategies

for disabled women.

Clinical Issue 6: Relationships

with family and significant

others

Importance of relationships in the

woman’s life. As described in

chapter 2, the “relational model”

(Covington and Surrey 1997) is

useful for understanding the

importance of relationships in

women’s lives and in the process

of their recovery. This model

emphasizes that relationships are

central in the emotional development of women. A woman’s

development hinges on her relationships with others, including

serving and caring for others,

and on her connections with others and feelings. These nurturing

and caregiving roles are organizing principles in a woman’s life,

which can be a source of great

strength during her recovery

(CSAT 1994b).

Women offenders often develop their dependency on drugs

early, frequently in early adolescence. Such adolescent drug

dependency interferes both with

a young woman’s cognitive and

emotional growth and development. These emotionally immature and dependent women need

the opportunity, in a drug-free

environment, to become emotionally mature adults capable of

real connection with others.

Many substance-abusing women

offenders have had few or no positive relationships in their lives.

Such women have no models for

developing healthy relationships,

nor do they even have a sense of

what a healthy relationship could

be. For a model of a healthy relationship, one resource is Leaving

the Enchanted Forest: The Path from

Relationship Addiction to Intimacy

(Covington and Beckett 1988).

Addicted women lose their

sense of self. Women offenders

who became dependent on alcohol and other drugs during their

teen years did not have a chance

to develop a deep inner sense of

self and of personal identity.

Without a sense of who she is, a

woman is incapable of having

real connections to others.

Recovery from addiction is about

expansion and growth of the self.

Family of origin issues. Women

also need to understand how

alcohol and drug problems may

have affected the family in which

they grew up, including the relations between family members.

Substance use patterns—and

relationships—are modeled within families. Norms about drinking

are “set” by family members as

well as by peers. Substance abuse

creates a dysfunctional family

structure, even for mainstream

families. Both this family dysfunction, and problems with

chemical dependency, tend to be

passed on from generation to

generation. In some cases, there is

a genetic predisposition to alcohol or drug dependence. But substance abuse is also learned.

Children and codependent adults

develop family roles and behavior patterns that help them survive in this environment. These

dysfunctional patterns persist

and limit the family members’

ability to connect with others and

to live a full and satisfying life.

Women alcoholics are more

likely than male alcoholics to

have a family history of alcoholism (Blume 1992). In State

prisons, 32 percent of women

inmates have a parent who

abused alcohol and 7 percent

have a parent who used drugs

(BJS 1994). In New Jersey, 43 percent of the women in State prisons lived with alcoholic relatives

while they were growing up and

45 percent lived with drug-using

relatives (Gonzalez 1996). Among

these women’s siblings, 39 percent have an alcohol problem

and 50 percent have a drug problem. 

Programming approaches. A

good treatment program needs

to establish an environment in

which women are encouraged to

grow in maturity and to connect

with others. Issues of trust, intiChapter 4—Clinical Issues in Treating Women Offenders

44
macy, and bonding are all central,

and the program approach

should encourage sharing of feelings and bonding among the

women. Staff members can be

important role models for how to

connect and relate to others in

healthy, caring relationships.

Programs also need to make

women aware of the emotional

dynamics in substance-abusing

families. These dynamics affect

not only the attitudes that a

woman develops while growing

up with a substance-abusing parent, but also the woman’s life

with her children.

Nearly half of female inmates

report that at least one member

of their immediate family has

been incarcerated (BJS 1994).

These women need to look at

what effect their family environment may have had on their attitudes, values, and behavior, and

on how they connect with others.

Several of the CSAT-supported

women’s programs provide education on the effects of family

addiction, and one has a group for

adult children of alcoholic families

(ACoA). A number of communities have ACoA groups that could

provide post-release support for

women and their families.

Clinical Issue 7: Attachment

to unhealthy relationships

Women who abuse alcohol and

other drugs tend to have relationships characterized by unhealthy

dependencies and poor communication skills (Bepko 1985).

Substance-abusing women

offenders often have unhealthy,

illusory, or unequal relationships

with spouses, partners, friends,

and family members (Covington,

in press). Some drug-dependent

women use addictive substances

to mask the inadequacies and

pain of their relationships—to

help them maintain relationships

with drug-using partners, to fill

up the void of what is missing in

the relationship, or to deny the

pain of being abused (Covington,

in press).

Problems connected with drugusing male partners. Having a

drug-using male partner is a particularly critical problem for the

incarcerated woman with substance abuse problems. Many

women say a man introduced

them to drugs, while men more

often began using drugs with

male peers. In one study, 33 percent of female heroin addicts said

a male friend, spouse, or partner

influenced their decision to use

narcotics. Only 2 percent of male

addicts said that a woman influenced their decision (CASA 1996).

It is accurate to say that some

of these women are addicted

both to the substance and to a

man who is addicted. A man

introduces them to drugs, and

they depend on the man for their

supply. In many cases, the

woman’s criminal activities can

result from dependent acquiescence in responding to the wants

of an addicted male partner. 

Lack of awareness of exploitation.

The woman may not recognize

that she has a history of being

exploited by the addicted partner. Physical, sexual, and emotional abuse often go hand-inhand with these relationships.

The woman may be part of a

drug-using environment in

which not only her partner, but

also her siblings and parent(s),

are involved with drugs.

Incarcerated women need to

build the strength to break their

unhealthy dependency bonds on

their partners, not only as a step

toward substance abuse recovery

but to prevent recidivism to criminal activities through the partner’s influence.

Programming approaches. Programs for incarcerated women

need to place an emphasis on

overcoming disempowerment

and disconnection from others as

a basis for recovery. This

approach looks at a woman’s

relationships in terms of her own

needs, her sense of self, and the

responsibility she owes to herself.

The woman needs first to understand what a healthy relationship

entails, so she is able to assess her

own relationships. Before entering treatment programs, many

women do not see how they are

being exploited or even realize

that they are being abused.

Through an effective treatment

program, the woman finds that

she can care about others, while

also making responsible choices

in her own behavior. She learns

that she has a responsibility to set

boundaries and take care of her

own needs (Beattie 1989, 1990).

For a woman to break her pattern

of unhealthy relationships, she

needs help to:

Chapter 4—Clinical Issues in Treating Women Offenders

45

A good treatment program needs to establish an

environment in which women are encouraged to

grow in maturity and to connect with others.
• Recognize intimacy and

friendship, as distinct from

sexuality

• Develop trust in herself as a way

of developing trust in others

• Attend to her own needs and

identify how these needs could

be met through friendship and

support from others, especially

from other women

• Develop actual relationships of

trust and support with others 

• Understand the different qualities of dependence, independence, and interdependence

• Identify and deal with any

codependent behaviors in

which the woman represses

her own feelings, neglects herself, and doesn’t set her own

boundaries

Many drug-dependent women,

when they leave prison or jail,

will face the necessity of cutting

themselves off from the significant people in their lives. To

maintain recovery, the woman

needs to live in a safe and drugfree environment. She needs to

be independent from addicted

family members—whether a

partner, a brother or sister, or a

parent. Treatment programs need

to prepare women to make this

kind of emotional break, and also

to help the woman find safe and

drug-free housing and a network

of support.

Clinical Issue 8: Interpersonal

violence, including incest, rape,

battering, and other abuse

Research shows that a high proportion of both alcoholic women

and those addicted to drugs have

a history of being physically or

sexually abused. Incarcerated

women, particularly those with

substance abuse problems, have

almost universally suffered some

form of violence, including sexual abuse as children.

Two of every three women

offenders ran away from home at

some time as children (a frequent

reaction to abuse at home); about

one in every four have attempted

suicide; and nearly seven of

every 10 offenders were victims

of severe and prolonged physical

and sexual abuse primarily as

children, but continuing into

adulthood for many (Lord 1995,

p. 261). At Forever Free and WCI

Village—both CSAT-supported

prison programs—the project

directors estimate that 90 percent

of their clients have suffered

some form of abuse from an early

age, and 90 percent of that is sexual abuse.

Sexual abuse during childhood

is particularly devastating, since

it can lead to distrust, depression,

anxiety, shame, and poor selfimage, all of which can hinder

recovery from addiction (Harvey

et al. 1994). Violence has a psychological impact on women that

is manifested in such disorders as

depression, post-traumatic stress

disorder, and low self-esteem.

Among pretrial jail detainees in

the large-scale study in Chicago,

fully one-third (34 percent) met

the criteria for post-traumatic

stress disorder (Teplin et al. 1996).

Many studies have shown the

correlations between domestic

violence and substance abuse.

Because so many substanceabusing women offenders are

involved in relationships with

substance-abusing men, the

women suffer a high level of

verbal/physical abuse and victimization. Both victimization

and post-traumatic stress disorder are related to relapse in

women (Root 1989).

Over the past decade, a good

deal has been learned about the

etiology of domestic violence and

battering and about strategies for

helping women to avoid and

escape such relationships. Most

researchers now view violence

against women in a broad social

and cultural context, not solely as

a mental health problem resulting from individual pathology.

The psychological model

explains violence as a manifestation of both individual psychopathology and learned

behavior, with roots in early

childhood abuse, family dysfunction, drug abuse, or disorders of

personality, thought, or impulse

control (Thorne-Finch 1992). In

accord with this view, intervention strategies for women need to

be comprehensive in approach.

The programming approaches.

Treatment programs for incarcerated women need to start with

the recognition that many of the

Chapter 4—Clinical Issues in Treating Women Offenders

46

Incarcerated women, particularly those with

substance abuse problems, have almost

universally suffered some form of violence,

including sexual abuse as children.
participants have suffered from

physical, verbal, psychological,

and sexual mistreatment (Miller

1991, Mondanaro et al. 1982). For

many, this abuse is a central factor in their addiction and in their

inability to maintain recovery.

Women who return to violent

relationships tend to relapse

(Miller et al. 1989).

Establishing an environment for

recovery. According to Herman

(1992), in her book Trauma and

Recovery, “Survivors feel unsafe

in their bodies. Their emotions

and their thinking feel out of

control. They also feel unsafe in

relation to other people” (p. 160).

In the early stages of recovery

from trauma, the essential element is safety (Herman 1992). A

woman must feel that she is in a

safe environment, both physically and emotionally. Successfully

establishing such an environment within the prison or jail setting is primary.

Working through feelings about

abuse. The second essential element is to help the woman confront and deal with her feelings

about the emotional and physical

trauma she has endured. As one

of the CSAT program directors

stated, “The abuse these women

have suffered is at the core of

their substance abuse. If women

don’t have a chance to work

through their rage, they soon

relapse and end up right back in

prison.” For women, the issue of

abuse is a sensitive, emotionally

charged issue. Project staffs recommend addressing this issue in

various ways, depending on the

stage in the treatment process

and the length and intensity of

the program.

* * * * * *

How deeply to probe about feelings about abuse during screening is discussed in chapter 6, in

“Stage 1: Screening and

Assessment.” The most effective

ways to handle issues of sexual

and physical abuse in short and

longer term programs are also

discussed in chapter 6.

* * * * * *

How best to introduce these

sensitive issues will depend on

the woman’s readiness to

acknowledge the abuse and to

process her feelings. For some

women, the preferred way to

handle issues of abuse is in

women’s process groups. Other

women may fare better with

individual therapy.

Within their process groups,

the CSAT-supported programs

have chosen to deal with these

sensitive issues in two different

ways. Some programs consider

violence, victimization, and

abuse to be so pervasive that it is

a subject which emerges

throughout all the group work.

Chapter 4—Clinical Issues in Treating Women Offenders

47

Resources

Treatment Protocol: Domestic Violence and Substance Abuse

For an introduction and recommendations on treating substanceabusing clients who are the survivors or perpetrators of domestic

violence, order CSAT’s recent guidelines produced by a panel made

up primarily of domestic violence experts. The book is Substance

Abuse Treatment and Domestic Violence, Center for Substance Abuse

Treatment (CSAT), Treatment Improvement Protocol (TIP) Series,

No. 25, DHHS Pub. No. (SMA) 97-3163. Rockville, MD: Substance

Abuse and Mental Health Services Administration, 1997b. This guide

includes an overview of female survivors and male batterers; and

covers screening and referral of survivors and batterers in substance

abuse treatment programs; legal issues; community linkages and

coordination; Federal confidentiality regulations; assessment instruments in English and Spanish; a sample personalized safety plan for

survivors; and resources and services. All TIPs are available free

through the National Clearinghouse for Alcohol and Drug Information

(NCADI), 1-800-729-6686.

Bibliography: Women, Violence, and Substance Abuse

Treatment

To learn more about women, violence, and substance abuse

treatment, order CSAT’s selected bibliography of articles and books

published on this topic since 1990, as well as other resources. The

report is titled Women, Violence, and Substance Abuse: Selected

Bibliographies, 1990-1998. It was prepared for the Center for

Substance Abuse Treatment by the National Evaluation Data and

Technical Assistance Center (NEDTAC), April 1998. The report is

available on the Internet at: [http://neds.calib.com].
This avoids any stigma attached

to a special group on the topic.

Other programs utilize a variety

of specific groups, such as:

Domestic Violence and Abuse,

and Surviving Sexual Abuse.

Staff need to be aware that

many of these women have been

so violated since childhood that

they don’t even recognize they

have been abused. It is important

to raise their awareness about

their personal rights and boundaries, and about what constitutes

verbal, physical, and emotional

abuse. Only then can the women

set their own personal boundaries.

Racial and cultural differences.

The patterns and outcomes associated with violence do vary,

depending on the woman’s

racial, ethnic, and cultural background. Most researchers now

agree that domestic violence

does exist in a social and cultural

context (Kanuha 1994, p. 430).

Research is beginning to show

what the differences are across

cultural lines on this issue, and

providers need to be sensitive

and knowledgeable about these

complex cultural differences

(Comas-Díaz and Greene 1994).

For a review of the primary literature sources discussing cultural

patterns in domestic violence, see

Kanuha (1994).

Kanuha (1994, pp. 446-449)

discusses intervention strategies

with women of color in battering

relationships, both in terms of

individual clinical interventions

as well as organizational development activities. Studies suggest that having social supports

available, such as social networks and extended family, is a

positive factor in helping

women of color perceive options

for leaving their battering partners (Coley and Beckett 1988).

Kanuha (1994) recommends

comprehensive approaches. She

suggests that, for women of

color, individual therapy can be

a helpful tool but it needs to be

incorporated with “group work,

educational sessions about the

etiology of violence against

women ... family therapy, and

most importantly, culturally

specific healing regimens and

ceremonies.” 

Battering in lesbian relationships. Battering and domestic violence may be present in lesbian as

well as heterosexual relationships, and is often related to drug

abuse. The isolation and invisibility that is enforced by society

makes this a difficult issue for any

woman, and this difficulty is compounded for women of color.

Separate groups for lesbian

women are desirable, since these

women may not feel comfortable

in support groups for battered

heterosexual women (Kanuha

1994). 

Clinical Issue 9: Eating

disorders

The culturally driven urge to be

slender is widespread among

women in the United States. On

any given day, from 33 to 40 percent of American women are trying to lose weight (NIH 1992).

Substance-abusing women are

particularly prone to eating disorders. In part, this is because

cocaine, heroin, and tobacco are

all linked to being thin. Women

who give up these substances are

likely to gain weight. Bulimia and

anorexia occur more frequently

among alcoholic women than

other women.

Among the women offenders in

the CSAT demonstration programs, eating disorders are not a

major problem. Some information

suggests that the cultural pressures to be thin may not be as

strong for women of color as for

other groups. In the CSAT programs, nutrition is the more

important concern. Incarcerated

women demonstrate a number of

issues around eating. One of these

is cultural: the fact that women

and mothers are equated with

nurturing and food. Addiction,

recovery, and relapse are associated with drastic fluctuations in

weight loss and gain. Women in

institutional settings may be

rewarded for gaining weight

because of the perception that

extra weight signifies a woman is

not using drugs. Weight gain may

be rewarded because of the perception that extra weight signifies

no drug use. In prison, women

who have been heavy cocaine or

heroin users will tend to gain

weight. Obesity can also result

from the heavy prison diet, often

designed for men.

Good nutrition is a problem.

Many of the women have never

had a well balanced, nutritional

diet. The women tend not to

have knowledge about nutrition

and good eating habits.

Establishing good nutrition, and

reducing food cravings from

nutritional imbalances, is important for preventing relapse.

Although the CSAT-supported

programs did not focus on nicotine

addiction, this can be an important

issue in prisons and jails. The current information about nicotine

addiction suggests that, particularly in the case of young white

women, nicotine addiction is on

Chapter 4—Clinical Issues in Treating Women Offenders

48
the rise. Smoking is used to control

weight gain. However, the same

information suggests that smoking

is on the decline among African

American teenage girls because

the cultural pressures to be thin are

not as strong.

Women in prisons and jails

may actually be heavier smokers

than male inmates. An increasing

number of prisons and jails are

becoming smoke-free environments, and nicotine addiction

then becomes a necessary treatment issue. The OPTIONS

Program in Philadelphia is one

model that addresses this issue.

* * * * * *

For program descriptions and

contact information on eating

disorders, see chapter 8.

* * * * * *

The programming approaches.

Because of the high rate of malnutrition among substance-abusing women offenders, programs

need to educate the women

about proper nutrition. In prison

TC settings, it may be possible for

the women to plan and cook

their own meals, which gives

practical benefits. The women

need to know how to prepare

nutritious, well-balanced meals

on a low budget. Many of the

CSAT-supported programs provide educational sessions on

nutrition.

In general, prisons and jails

often do not provide the types of

foods most appropriate and

desirable for women. Treatment

programs may not be able to

influence their institution’s food.

However, the kinds of concerns

expressed by the CSAT advisory

group were that (1) institutional

food tends to be too heavy on

meat, cheeses, and starches, so

the women gain weight, (2)

women who are vegetarian have

difficulty achieving a balanced

diet, and (3) meals may not be

nutritionally adequate for pregnant women.

The most desirable physical

arrangement is for incarcerated

women’s treatment programs to

be located in their own separate

space. The women eat together

in their unit rather than with the

overall jail or prison population.

Under these conditions, program

providers may be able to provide

meals that demonstrate good

nutrition for women.

Clinical Issue 10: Sexuality,

including sexual functioning

and sexual orientation

Women often go through substance abuse treatment without

ever addressing issues of sexuality and intimacy. Yet sexual dysfunction is very common among

women with substance abuse

problems, often predating their

problem drug use. It has been

reported that only 55 percent of

women recovering from alcohol

abuse report satisfaction with

their sexual functioning, compared with 85 percent of nonalcoholic women (Covington

1991a). Contrary to social stereotypes, alcohol depresses a

woman’s interest in sex. There is

also a lack of sexual desire among

heroin-addicted women. Alcohol

and drugs will aggravate, not

help, a woman’s sexual dysfunction.

Developing a sense of healthy

sexuality is tied to a person’s

sense of self-worth. It represents

the integration of the biological,

emotional, social, and spiritual

aspects of who the woman is and

how she relates to others

(Covington 1991a). A woman’s

sense of her sexuality is a developmental process that occurs

over time. For women offenders,

this normal developmental

process has often been interrupted by addiction and distorted by

her personal experiences. She

may never have experienced sexuality without being under the

influence of alcohol or other

drugs. 

Few women in prison have a

positive view of sex. Some have

been prostitutes, many have

been sexually abused, and most

connect sex with shame and guilt

(Covington, in press). Even

women who have been the most

sexually active may have little

accurate information about sex.

Incarcerated women have a

number of other issues around

sexuality. Women with substanceabuse problems are frequently

confused about the difference

between intimacy and sex. These

women may never have experienced intimacy with another person, so they have difficulty in

achieving intimacy in their relationships. It is common for these

Chapter 4—Clinical Issues in Treating Women Offenders

49

Developing a sense of healthy sexuality

is tied to a person’s sense of self-worth.
women to confuse sexuality with

the intimacy they really seek, on

the assumption that sex and intimacy are the same.

Sexual identity and self-acceptance may be an issue for some

lesbian and bisexual women.

Older women have their own

issues. The many women with

severe addiction problems can

experience physiological consequences, such as hormonal

changes and liver damage, that

affect their sexual functioning.

One CSAT-supported program

reports that many of the women

in the program, as a result of

severe substance abuse, are starting menopause very early—in

their late 30s and early 40s.

The programming approaches.

Sexuality is an essential area for

addiction treatment programs to

address, because issues around

sexuality are a major cause of

relapse among women. Approaches need to help women

work through their sexuality

issues on a number of dimensions. One helpful resource is the

document, Awakening Your

Sexuality: A Guide for Recovering

Women and Their Partners

(Covington 1991a). Treatment

needs to help women understand such issues as:

• Basic information about drugs

and sexuality. As a first step, all

the women need to know

about the role that alcohol and

drugs can play in diminishing

sexual desire and sexual functioning.

• Common concerns among recovering women. The program

should also help women

understand that they share

many concerns common to

women offenders entering the

early stages of recovery. These

include concerns about sexual

dysfunction, shame and guilt,

sexual identity, prostitution,

sexual abuse, and the fear of

having sex “clean and sober.”

• The relationship of substance

abuse to physical and sexual

abuse. The women should

understand that substance

abuse is related to physical and

sexual abuse. Alcohol consumption, for example, has

been linked to assault, rape,

spouse and child abuse, and

fight-related homicide. Many

women in this population will

not be able to separate sexuality from issues of incest, rape, or

sexual abuse. These are often

the core problems that underlie sexual dysfunction in these

women. Both individual and

group counseling are helpful

approaches. Several of the

CSAT programs offer groups

on “surviving sexual abuse.” 

• Sexual identity and selfacceptance. Women who are

lesbian or bisexual may feel

shame and stigma, which can

be a factor in relapse. Women

of color face particular difficulties in dealing with three

sources of stigma—their sex,

their race or ethnicity, and

their sexual preference. Special

groups for lesbian and bisexual

women are one programmatic

approach.

• Prostitution. Many of the

women have either been prostitutes or have exchanged sex

for drugs. These bartering conditions, especially in “crack

houses,” may be degrading

and demeaning for teenage

girls and women. Substanceabusing women involved in

this kind of “sex for survival”

have issues on many levels,

from shame to concerns about

intimacy and self. The women

need help in exploring their

lifestyle and they also need the

practical tools to change that

lifestyle. Either a group or individual counseling approach, or

both, is helpful. The SISTER

program offers specific counseling for prostitutes in a group

called the “Ex-Sex Workers

Group.” 

Clinical Issue 11: Parenting

Many disadvantaged women

with substance abuse problems

have grown up in families where

they experienced parental neglect or abuse. These women do

not know how to be nurturing

parents because they never experienced nurturing as children.

The women often have no role

model for consistent, positive

parenting. In addition, experts

who treat poor, substance-using

women report that disadvantaged women often do not know

what normal child behavior is.

They tend to have unrealistically

high expectations about how

their children should behave,

Chapter 4—Clinical Issues in Treating Women Offenders

50

Many disadvantaged women with substance abuse

problems have grown up in families where they

experienced parental neglect or abuse.
combined with harsh disciplinary practices.

Incarcerated, substance-abusing women have an acute need

for help with mothering behavior. When mothers have been

imprisoned, their children are

likely to feel abandoned and to

demonstrate both behavioral and

emotional problems. If the mother used drugs during her pregnancies, her children may also

have subtle behavioral or cognitive problems that create a need

for special tolerance and parenting skills.

It can be emotionally difficult

for treatment staff to accept the

fact that some women will not be

reunited with their children or

may not want to have custody. In

some cases, reunification will not

be practically possible or in the

best interests of the children.

Whatever the outcome regarding

eventual custody, these are difficult, painful parenting issues for

women to handle. Treatment

staff can help incarcerated

women assume—and plan for—

as great a role as possible in the

decisions about their children.

But staff need to be sensitive and

self-aware, so they do not inadvertently increase the guilt these

women clients already feel about

their children and their inadequacies as mothers.

The programming approaches.

Relationships with her children

are almost always a central focus

in a woman’s sense of self and

her emotional life. Parenting and

mothering are important issues.

Many addicted women offenders

need to learn what positive parenting entails. The longer term

treatment programs offer the

chance for women to observe

and practice how to nurture

themselves and their children.

These longer women’s programs

(2 months or more) address parenting issues through a variety of

education, skills-building, counseling, and child visiting/observation efforts.

When the child visits, skilled

observation of the interaction

between mother and child can

give a concrete basis for therapy

with the mother. As an example,

at WCI Village, one mother was

observed to be functioning as a

sister to her visiting children,

rather than as a parent; she was

then helped to understand and

assume a parental role.

The CSAT grantees suggest the

following topics are important to

cover in parenting programs:

• Education on child development. This education needs to

focus on normal patterns of

child development and what is

reasonable to expect in terms

of behavior at different ages.

Incarcerated mothers need

special help concerning the

feelings and behavior of children after the separation from

her. Their behavior may be

very difficult for a parent to

handle. 

• Family communication. Among

the skills needed are listening

skills, confrontation, resolving

conflicts, handling stress,

expressing emotions, redirecting children’s misbehavior,

building self-esteem, and effective discipline.

• Fetal alcohol syndrome (FAS),

fetal alcohol effects (FAE), and

drug exposure in utero. The

women need to be aware of

possible effects on their children from the mother’s use of

alcohol and drugs during pregnancy. Such children are often

not identified by the schools,

although the children may be

experiencing learning disorders, attention deficit disorder,

and other problems. These

children may be fussy and

hard to console as infants, and

later may be nervous and distractible with subtle behavior

problems. Women need to

know what to look for and

what help is available for the

children.

The types of interventions

offered by the CSAT-supported

women’s programs are parenting

education groups, parenting

counseling groups, counseling

and therapy for the individual

woman as a parent and for the

entire family, and a group dealing with mother/daughter issues.

Clinical Issue 12: Grief

Clinical evidence suggests that

women will experience a sense of

acute grief and loss in acknowledging their drug use and need

to sustain sobriety (Zankowski

1987). Incarcerated addicted

women are also faced with

almost overwhelming grief and

loss as the result of their past

lives. To recover from addiction,

women need to work through

their feelings of guilt and shame,

as well as loss. Several of the

CSAT women’s programs report

that it is difficult for their women

clients to recover and maintain

sobriety if they do not go

through a grieving process first.

There is the loss of the substance itself, which has been

serving some critical function for

the woman. By the time a

woman is incarcerated, she has

suffered overwhelming losses—

her children, her partner, her selfChapter 4—Clinical Issues in Treating Women Offenders

51
respect, often her health and

appearance. The many women

who have been in abusive relationships with substance-abusing

partners will come to understand

that their lives must start over.

They must give up the people

who have been important to

them and build other, positive

relationships. Women with parents or siblings who abuse drugs

will have to distance themselves

from their families in the interest

of recovery. 

Women also experience grief,

shame, and guilt associated with

the real damage they have done

to those they love, particularly

their children, and to themselves.

Several of the CSAT grantees

have stressed how important it is

to have some spirituality component in work with women. If

women are to endure and rise

above all this grief and pain, then

there must be the sense that it

has all been for some reason.

Spirituality can be important in

providing this sense of purpose.

The programming approaches.

Programs designed for women

use a philosophy that focuses on

the strength of each individual

and uses her experience, both

past and present, as learning

tools rather than as sources of

grief and shame (Walker et al.

1991). The women need to take

responsibility for the harm they

have done to others, while also

learning to value themselves.

The CSAT-supported programs described in this Guide use

either a modified 12-Step model

or a TC that includes 12-Step

principles. They believe that the

spirituality embedded in the 12-

Step model is an important

advantage for treating women. A

Woman’s Way Through the Twelve

Steps is one resource that illustrates the different ways in which

women can connect to a spiritual

source and acknowledge their

responsibility and grief, while

also growing in terms of self

(Covington 1994).

Many of the CSAT grantees

stressed that helping women to

connect to their own definition of

the spiritual is critical to their

recovery process. Religion and

spirituality are not the same,

although for some women they

are connected. Religion rests

with institutions, and is based on

forms, dogma, and rituals.

Spirituality, for women, is about

“transformation, connection,

wholeness, meaning, and depth”

(Covington, in press).

Women connect to their inner

sense of spirituality in many

ways. Those who have rejected

religion must find a different

path; others may be drawn back

to the religion of their childhood.

Covington (in press) reports that

she has found it useful to give art

history books to women in recovery groups. Women connect with

the energy of the prehistoric

earth goddesses, worshipped in

apparently all cultures for thousands of years before patriarchal

religions developed. It is affirming for women to realize that

they are part of a long history in

which females have been revered

as “birthers, growers, and caregivers.” 

Clinical Issue 13: Work

Both low levels of education and

unemployment are correlated

with substance abuse for women.

Incarcerated substance-abusing

women are extremely vulnerable

to recidivism and to relapse if

they cannot sustain themselves

(and their families) economically

through lawful employment.

This factor has become critical

since passage of the Federal welfare-to-work legislation. Women

formerly sustained through welfare programs will find this to be

only a temporary help, if they are

eligible at all. The legislation

requires, unless the State opts out

or modifies the requirement, that

anyone convicted of a drug-related felony after August 22, 1996

will not be eligible for cash benefits or food stamps. Women in the

CSAT-supported programs present the following issues:

• Education. The low educational

level of women offenders in the

CSAT prison demonstration

programs adversely affects their

ability to sustain themselves

and their families economically

and legally. Among the CSAT

programs, the Oregon Recovery

In Focus program has the highest average educational level of

women clients—11th grade.

The Baltimore pre-detention

program is typical, with 65 percent of clients not graduated

from high school. All the CSAT

programs encourage education, especially acquiring a

GED, as a base for achieving

self-sufficiency. 

Chapter 4—Clinical Issues in Treating Women Offenders

52

Spirituality can be important in providing

a sense of purpose [for their grief and pain].
• Employment. In prison studies,

incarcerated women in general

often mention substance abuse

as a reason for their unemployment. Few women in the CSAT

programs have had any specialized vocational training

and most are unemployed. As

an example, the Baltimore pretrial program reports that more

than 70 percent of their clients

are aged 26-40 years and only 8

percent state that wages/salary

were their primary income

source before incarceration;

just 12 percent report working

full- or part-time in the past

year. Some 32 percent of the

women receive public assistance and 65 percent report

being unemployed.

The programming approaches.

Substance abuse treatment programs do not generally provide

vocational training for women

during incarceration or after their

release. Actual training is done as

part of the institutional programming, in work-release programs,

or through community referrals.

* * * * * *

The coordination of treatment

with prison work programs is

discussed in chapter 5.

* * * * * *

The treatment program’s role

is to provide the planning, outreach, and advocacy needed to

equip their women with necessary job skills. Women suffer

from a dearth of the well-paying,

unskilled labor jobs available for

men. Since women often support

a family, not just themselves,

there needs to be a real focus on

preparing women for jobs that

pay a decent living wage. In the

CSAT-supported programs, the

following types of help are provided:

• GED testing and assessment

and adult basic education to

pass the GED (graduate equivalency diploma)

• Vocational testing for training

programs

• Job hunting skills, including

writing resumes, interviewing

• Vocational planning

Clinical Issue 14: Appearance

and overall health and hygiene

Physical and dental health.

Typically, indigent drug-abusing

women do not seek treatment for

physical ailments until their conditions are serious (Prendergast

et al. 1995). Women come into

prison with more medical needs

than do men (Lord 1995). Drugabusing women enter incarceration with a host of untreated

mental and physical health problems. All drug users, and cocaine

users in particular, are at

increased risk for a range of

physical problems, including

extreme weight loss, dehydration, digestive disorders, skin

problems, dental problems,

gynecological and venereal infections, tuberculosis, hepatitis B,

hypertension, seizures, respiratory arrest, and cardiac failure

(Daley and Przybycin 1989).

For drug-abusing women

offenders, medical treatment is

important not only for reasons of

health but to increase their selfesteem. For women, body image

is tied to self-esteem. The CSAT

grantees report that women

offenders who have used crack

cocaine heavily often present

with disfiguring facial sores,

missing teeth, and other physical

evidence of neglect. Because of

the prison diet, women may have

gained considerable weight and

consequently feel obese and

unattractive. CSAT’s advisory

panel stressed that resolving

these types of problems is important, because it bolsters the

women’s sense of self-worth.

The programming approaches.

Medical services need to be provided for incarcerated women

with substance abuse problems.

Many jails and some prisons lack

the facilities to provide women

with the level and type of care

they need. For treatment programs for incarcerated women,

the approach is threefold:

• The program needs to arrange

for adequate medical and dental services. Staff may need to

advocate on behalf of the

women for adequate medical

and dental care. It is important

to help women gain access to

the services available within

the jail or prison setting.

• The program should help

women understand how substance abuse has affected their

health and underscore their

responsibility for the health of

their own bodies.

• The program should stress that

it is important whether the

women’s teeth are fixed and

their physical problems are

treated. This kind of attitude

says, “you are a worthy person

and it matters how you look

and feel.” 

Pregnant women offenders.

Most of the pregnant women

coming into prison are young

first offenders in need of intensive drug treatment (Lord 1995).

Alcohol- and drug-abusing

women who are pregnant when

they enter prison face severe,

multiple problems. The outcome

Chapter 4—Clinical Issues in Treating Women Offenders

53
of the pregnancy is often complicated not only by the mother’s

substance abuse, but by her general ill health, poor nourishment,

sexually transmitted diseases,

battering, and late or no medical

attention. These are high-risk

pregnancies. Especially in jails,

the women may receive no medical care at all or inadequate prenatal care. The detoxification

process can be hazardous for the

fetus. 

The programming approaches.

Substance-abusing women who

are pregnant when they enter

custody need specialized obstetrical care for their high-risk pregnancies. The CSAT Treatment

Improvement Protocol (TIP 2),

Pregnant Substance-Using Women

(CSAT 1993b), offers guidelines

for handling detoxification from

heroin and other drugs. The consensus panel, in developing TIP

2, found that many protocols

used for detoxification did not

address the special cautions

required for pregnant women.

It is particularly important to

identify and treat pregnant

women who are HIV positive.

Transmission from the mother is

the foremost cause of pediatric

AIDS in the United States.

Medical treatment with pharmacotherapy of HIV-infected pregnant women can now cut by 68

percent the chance that the

mother will transmit the virus to

the fetus (CDC 1994).

Most institutions automatically

remove the baby after birth from

mothers who are pregnant when

they enter prison. Among CSATsupported programs described in

this Guide, both the WCI Village

TC and the Recovery In Focus

programs have special components designed to help new

mothers. WCI Village helps a

pregnant woman prepare for loss

of the baby and lets her help

choose the baby’s caregiver, if

possible. The In Focus program

operates a volunteer foster parent program for the babies. These

volunteer parents bring babies

for visits to the mother.

AIDS and other sexually transmitted diseases. Women who

inject drugs or who have druginjecting sex partners face

increased risk of contracting

HIV/AIDS. An appreciable number of drug-abusing women

already have HIV infection or

untreated sexually transmitted

diseases (STDs) when they enter

prison. The costs of medical care

in prison have risen dramatically

with the advent of the AIDS epidemic. Among State prison

inmates nationwide, a higher

percentage of women than men

test positive for the human

immunodeficiency virus (HIV)

(BJS 1994). In New York, one out

of every five women entering the

State prison system is HIV positive (Lord 1995).

In addition, women who

smoke crack are emerging as a

population at equal or greater

risk than intravenous drug users

for HIV and other STD infections

(Inciardi et al. 1991). This is

because of high-risk sexual

behaviors, particularly the barter

of unprotected sex for crack or

money with numerous sex partners. A three-city study by the

Centers for Disease Control and

Prevention found that the overall

prevalence of HIV among crack

users was 15.7 percent, with

women having higher rates of

infection than men (Edlin et al.

1994). In New York City, where

rates of HIV infection are high,

the available data suggest that

the rate of infection is between 12

and 20 percent for crack users

who do not have other risk

behaviors (Fullilove and Inciardi

1995).

Rural women who use crack

cocaine seem to be at as great a

risk for HIV infection and transmission as inner-city women. A

study of 60 crack-using women

in rural Georgia and Miami

showed that of those tested for

HIV, 15 percent of the Miami

women and 11 percent of the

rural Georgia women were HIVpositive (Forney et al. 1992).

The programming approaches.

CSAT grantees are required to

make testing and screening for

infectious diseases, including

HIV, available for all clients. Such

testing involves a number of confidentiality issues, which programs need to understand and

be prepared to explain to women

offenders. Pre-test counseling is

required for all participants who

elect to be tested. Programs that

screen for HIV also need to be

sure to provide counseling for

those who test HIV-positive.

All the CSAT-funded women’s

prison programs provide education and counseling on HIV and

other high-risk health behaviors.

Even the 2-week Baltimore pretrial program addresses the prevention of HIV and sexually

transmitted diseases (STDs);

medical screening to identify

women with STDs is available

through the detention center

medical services program.

Chapter 4—Clinical Issues in Treating Women Offenders

54
* * * * * *

This issue is covered further in

chapter 7, in the section on working with the medical staff.

* * * * * *

Clinical Issue 15: Isolation

related to a lack of support

systems

Having a network of people to

turn to is a critical element for

women in recovery. Because substance abuse is a chronic disorder,

recovery is punctuated for most

individuals by “slips,” or periods

of relapse. It is important for a

recovering woman to have people who will support her at these

times. The families of many

incarcerated women cannot provide this support. For these

women, their families may be

one source of their substance

abuse problem, rather than a

support in recovery.

Who is in a woman’s personal

network of associates is absolutely critical after the woman leaves

prison or jail. Her prior associations will mainly be other substance-abusing individuals. If the

woman does not cut herself off

from these associations and step

into a new network of nonabusing people, she is likely to

relapse.

Programming approaches. All

the CSAT-supported treatment

programs consider it vital for

addicted women offenders to

have a support system after they

leave the institution. Incarcerated

substance-abusing women can

benefit from help aimed at developing this support. First, trust is a

real issue. Many women offenders will need the experience of

connecting with other women

and learning to trust them before

they will become able to utilize

peer support. Second, women

offenders may find it hard to

believe that success is possible for

women in their situation—in

trouble with the law and with

severe substance abuse.

Successful role models—women

who have themselves been substance-abusing offenders—can

provide both understanding support and the proof that success is

possible. 

The CSAT programs use two

different approaches. First, several jail and prison programs have

developed their own alumna

groups to offer support to the

women after release. The second

approach is to encourage program

participants to become involved in

community mutual-help groups.

These groups sometimes meet in

jails, so that program participants have already made personal contacts before they leave

the institution.

Program-sponsored groups.

Support groups are an integral

part of the intensive program

efforts to keep women offenders

involved in treatment after their

release from jail or prison. Some

of these groups include:

• A mentor program that matches each individual offender

with a trained woman volunteer in her community; these

women are successful role

models recruited through professional and community

organizations

• Several support groups made

up of women ex-offenders

who have graduated from the

treatment program

• A Winners Circles mutual-help

group, part of a new national

mutual-help organization for

people who are addicted exoffenders

* * * * * *

Chapter 6 provides information about support groups developed and sponsored by the CSAT

women’s programs.

* * * * * *

Twelve-step and other mutualhelp groups. All of the CSAT-supported programs described in

this Guide utilize 12-Step study

groups within their treatment

programs. All the programs also

encourage women to participate

in mutual-help support groups,

such as Alcoholics Anonymous

(AA), Narcotics Anonymous

(NA), Cocaine Anonymous (CA),

and Women for Sobriety. Very

strong efforts go into making

arrangements to connect women

after custody with support

groups in their local communities. These groups offer many

advantages for women—the

groups are free, available at a

variety of day and evening

Chapter 4—Clinical Issues in Treating Women Offenders

55

All the CSAT-supported treatment programs consider

it vital for addicted women offenders to have a

support system after they leave the institution.
hours, and provide a nonusing

peer support group.

Women-only groups are especially important during the early

stages of recovery for women

who have a history of abusive

relationships with men. The

women-only support groups

have keen importance for women

for the following reasons:

• Their spiritual component.

Addicted women offenders

need not only hope but a sense

that their lives, and the pain

and suffering they have

endured, have meaning. The

12-Step groups offer women a

spiritually sustaining process

for change.

• Their chance for bonding with

other women. The 12-Step

groups, by providing peer support and bonding, provide one

key way to keep women

involved and committed to

recovery after release from custody.

• Their opportunity for peer modeling. Women offenders get

both encouragement and practical help from women like

themselves who have struggled with a range of obstacles

and are now recovering.

Although not treatment per se,

the great value of these mutualhelp groups lies in their capacity

to supply support at all stages in

the recovery process. These

groups fit into a woman’s life

after her self-discovery and

recognition of an addiction problem. The groups work by giving

women a process for maintaining

their motivation and commitment to recovery. 

* * * * * *

For a helpful resource on how

mutual-help groups contribute to

recovery for women, see

Stephanie Covington’s “Sororities

of Helping and Healing” (1991b).

* * * * * *

Clinical Issue 16: Life plan

development

The woman with a severe substance abuse problem tends to be

living hopelessly in the present,

without any long-range goals or

plans for her life. The CSAT

grantees point out that incarcerated women enter their programs without the planning and

coping skills needed to make life

plans. The women first need to

grow in terms of self-esteem, selfassertion, and in their sense of

empowerment. These are the

sources of hope that a woman

will need to change her life. Then

these women need help in

acquiring the practical skills, such

as education and vocational

training, that form building

blocks for a life plan.

In addition, the ability to cope

with stress is an important factor

in avoiding relapse to drug use.

According to the CSAT grantees,

their women clients face extreme

levels of stress in their lives, combined with poor coping skills.

They need ways to cope with

both internal stressors, such as

lack of self-esteem, depression,

and separating self from abusive

relationships, and such external

stressors as finding a job and

managing on a small income.

Those working with substanceabusing women suggest that it is

important to introduce the

women to drug-free recreational

activities as well as to a host of

other coping mechanisms for

handling stress.

Programming approaches. The

substance-abusing woman offender needs to develop a vision

for her future and to create a life

plan. For addicted women

offenders, the goal is comprehensive: to help the woman remake

her life. The CSAT programs provide the scope to help a woman

develop and integrate the necessary pieces to build a sober, selfsustaining life for herself and

possibly also for her children.

Individualized treatment plan.

All the CSAT women’s programs

develop an individualized treatment plan for each woman. In

the longer treatment programs,

this plan evolves as the woman

works through the treatment

process. The plan helps a woman

think through not only her goals

and the steps toward recovery

from substance abuse, but also

the goals for her life. These

would include her hopes and

steps for reunification with her

children, her education, job

goals, and plans for housing.

* * * * * *

Chapter 6 describes the individualized treatment planning

done by CSAT programs.

* * * * * *

Life skills. An important piece

of the habilitation process is to

help women offenders develop

the life skills required to overcome the multiple problems they

will face upon leaving the institution. Many of these women lack

the basic skills to meet the

demands of day-to-day living.

Among the topics covered by the

Chapter 4—Clinical Issues in Treating Women Offenders

56
CSAT demonstration projects are

budgeting, grocery shopping,

cooking, practical problem solving, and assertive communication skills.

Recreational activity and stress

management. Another important

area is stress reduction. The

director of WCI Village says the

women are eager to learn skills

for controlling and reducing

stress, including meditation.

How to manage anger as well as

stress is also a component in six

of the CSAT-supported programs. Among the interventions

used by the CSAT programs are:

• Exercise classes

• Meditation 

• Yoga classes

• Relaxation techniques

• Acupuncture

• Art therapy

Many of the women don’t

know how to nurture themselves

or to have a good time. Leisuretime activities—including those

with children—help sustain

women in recovery. The women

also need to learn self-soothing

techniques in order to deal with

the many painful feelings that

surface when they are abstinent.

The CHOICES TC program in

Arkansas offers an unusual and

highly popular alternative—a

Ropes Course. The course, which

costs $25,000-$35,000 to install,

has poles that are 45 to 50 feet

high, combined with harnesses

and a zipline the length of a baseball field. Some of the treatment

staff and correctional officers are

certified instructors. The women

use the course in teams; it is a

tool that builds self-esteem, confidence, and trust among the

women as well as teaching

responsibility for self and others.

There are many different problem-solving scenarios (obstacles)

that teams must work together to

solve. The course experience

gives women a chance to share

an experience and talk afterwards about their feelings, as

well as providing them with a

tremendous sense of pride and

accomplishment.

Clinical Issue 17: Child care

and child custody

For mothers confined to prison,

their families are broken apart.

Two-thirds of women in State

prison have children under age

18 and, before being incarcerated, 72 percent of these women

lived with their dependent children (BJS 1994). When these

mothers enter prison, their children are placed in foster homes

or with relatives and friends; for

these women, separation from

their children is one of the most

damaging aspects of a prison

sentence (Berkowitz et al. 1996).

Imprisonment compromises the

incarcerated woman’s ability to

maintain relationships with her

children, thus adding to family

difficulties following her release

(Bloom et al. 1994). The psychological stress of incarceration

related to separation from family

and loss of control over their lives

may also exacerbate existing

depression or induce other mental health problems (Fogel 1993).

Family reunification issues.

Women who are pregnant when

they enter prison are nearly

always separated from their

infants soon after birth. The

infants go to foster care or to a

relative, and the mother has no

opportunity to bond with the

baby. Many of these women are

themselves products of the foster

care system, and fear what will

happen to their children.

Since the early 1980s, advocates for women prisoners have

pressed for services to assist

incarcerated women in strengthening and sustaining bonds with

their children. Child visitation

and other contacts are critical for

maintaining a mother-child

bond. Without institutional and

program support, these visits

tend not to happen. Although

nearly all State prisons allow

child visits, more than half of

women inmates never receive a

visit from their children (BJS

1994). Fewer than 40 percent of

jails nationwide permit contact

between women and their children during visits, and only 15

percent allow extended visits

between women inmates and

their children (ACA 1990, p. 45).

Advocacy. Many of the women

also need legal advocacy to regain

custody of their children. A

national project of Child Custody

Advocacy Services found that 80

percent of the women seeking

help with legal custody problems

had been incarcerated for drug

offenses or drug-related crimes

(Johnston 1995). This project

found a dramatic correlation

between mother-child reunificaChapter 4—Clinical Issues in Treating Women Offenders

57

The women are eager to learn skills

for controlling and reducing stress.
tion and post-release residential

drug treatment for mothers.

More than 90 percent of clients

released to residential drug treatment achieved reunification with

their children.

Programming approaches. One

of the most significant deficits of

male-oriented programs is that

they pay little or no attention to

the inmate’s role as the caretaker

of children. Approaches for

women offenders need to help

them cope with the concrete and

excruciating difficulties they will

face as the primary financial and

emotional support of their families. Planning should begin from

the woman’s first entry into the

program about her goals and

what kind of help she will need.

Even non-substance-abusing

women who are poor and single

can find the problems and challenges of being a single parent

almost overwhelming in our society. We should not minimize how

difficult this role is. The mother

in prison or jail is often concerned about losing custody of

her children. If she does have

custody, then she must be prepared to support and manage

her children after her release.

Programs need to focus on the

woman’s role as mother, on her

expectations and skills as a parent, and on improving her parenting skills.

Organizing visits between children and their mothers is one

important way of maintaining the

bond among families. A few

advanced programs across the

country use these family visits as

an opportunity to offer therapy

for families and for the children.

Engaging sentenced mothers and

their children in treatment together is most easily accomplished in

community alternatives to incarceration or in local jails. However,

involving the children is possible

in prison settings and is a promising strategy for helping incarcerated women. Several of the CSAT

women’s demonstration programs have strong family support

and reunification components.

This strategy is important for a

number of reasons.

• At least three-quarters of the

women will resume custody of

their children after release.

Their children are the most

important factor in their lives;

most women with children

want to be good mothers and

to be reunited with their children. This factor can be a major

motivation for women in seeking and staying in treatment.

• Parenting education and therapy can also help women meet

court-mandated requirements

and regain custody of their

children.

The CHOICES program has a

playground for children visiting

their mothers. At the Recovery In

Focus program, children come

for visits and a family therapist

conducts play therapy sessions

with the children. New mothers

receive education on bathing

babies and other care. In Focus

works with a church volunteer

program dedicated to helping

the women resume custody of

their children upon release. The

volunteers serve as foster parents

and legal guardians until the

women are released. The social

services department is usually

not involved. The volunteer foster parents bring the babies to

visit once a week.

In terms of legal advocacy, the

CSAT demonstration programs

have a number of strategies that

combine parent education with

family reunification efforts. In

addition to the parenting component, the SISTER project provides a legal advocate who helps

the women with custody and

other legal issues. An advantage

of a family reunification component is that it can realistically, and

professionally, address whether a

woman is ready to resume custody of her children. When necessary, counselors can help a

woman face and cope with the

fact that she is not at this point

able to care for her children. The

program can then help the

woman assume some control in

the decisions about what is best

for her and her children. 

One CSAT grantee points out

that the drive toward family

reunification should not obscure

a tragic reality—up to 25 percent

of these women will not get their

children back. The staff must also

assist women to live with this

reality. Several of the CSAT

Chapter 4—Clinical Issues in Treating Women Offenders

58

Organizing visits between children and their

mothers is one important way of maintaining

the bond among families.
grantees pointed out how essential spirituality is for women in

these circumstances. The women

need comfort and support in

coming to terms with their emotions, which include not only

guilt and grief, but relief as well.

This is a difficult issue not only

for the women but for the program staff to handle. Staffs tend

to project their own values on

women who don’t get their children back.

Additional Clinical

Issues 

The clinical issues shown in table

6, p. 40, which are part of CSAT’s

comprehensive treatment model,

are important issues for all substance-abusing women regardless of socioeconomic level. These

issues simply tend to be more

intense for the substance-abusing

woman who is disadvantaged

and incarcerated.

In addition, women being

treated within the criminal justice system present other serious

issues. These issues pertain to

coexisting psychiatric disorders

and criminogenic characteristics.

Clinical Issue 18: Coexisting

psychiatric disorders, including

depression

Alcohol- and drug-abusing

women have high rates of

depression and a number of other

psychiatric disorders. The coexistence of major mental illness, as

defined by the DSM-IV criteria,

can complicate both the diagnosis

and treatment of substance

abuse. Prisons and jails contain

many women who have coexisting psychiatric disorders along

with substance abuse problems.

In the past few years, ever

greater numbers of women

appear to be entering correctional systems who have prior histories of psychiatric hospitalization

and/or suicide attempts (Lord

1995, p. 264). Economically marginalized women with serious

mental illness, once institutionalized, are now living in the community, where they may fail to

seek help from mental health

clinics or may discontinue their

medication and treatment. Those

leaving mental institutions may

find little support from family or

community and then become

homeless. As these women make

their way from the streets to shelters, they frequently stop taking

prescribed medications and selfmedicate with street drugs that

are easily accessible. It is only a

matter of time before they

become caught up in the criminal

justice system.

Programming approaches. A

good treatment program for

women in the criminal justice

system will conduct mental

health screens to look for underlying mental disorders. With

women, the focus will be on

identifying co-occurring mental

disorders, including depression,

in addition to identifying criminogenic traits.

Traditionally, substance abuse

programs have not admitted

women with diagnoses of schizophrenia and similar psychotic

disorders. There is an overwhelming need within the criminal justice system for programs

that serve incarcerated women

who have coexisting psychotic

disorders and substance abuse

problems.

The CSAT-supported programs for incarcerated women

have made a concerted effort to

admit such women to their programs, provided that the women

are stabilized on appropriate psychiatric medications and are able

to handle the intensity and interpersonal demands of the program. Their experience is that

these women may need extra

time in the program and the

understanding help of skilled

staff, but they can be successful.

This approach requires close

coordination with the mental

health staff of the institution.

Institutional barriers often make

such cooperation difficult.

* * * * * *

The experience of CSAT’s

grantees with treating women

who have co-occurring mental disorders is summarized briefly in

chapter 7. See “Relationships With

the Medical and Psychiatric Staffs.”

* * * * * *

Ideally, treatment approaches

for substance abuse should be

designed to deal with a range of

women who may also exhibit

antisocial and other personality

disorders. It is important to be

aware that a subset of women

may have organic brain damage

and impairments resulting from

abuse and seizures. Some will

have low intelligence quotients.

Clinical Issue 19: Criminogenic characteristics

An important area where women

offenders differ from men is in

their level of sociopathy. A major

subset of male offenders meet

Chapter 4—Clinical Issues in Treating Women Offenders

59
DSM-IV criteria for having antisocial personality disorders.

These male offenders have personality patterns that are basically unsocialized, bringing them

constantly into conflict with

other people and society. Drug

treatment programs for male

offenders are designed to deal

with a high rate of sociopathy

and criminal thinking. One of the

most sophisticated criminal justice screening systems—that

used by Colorado—classifies

offenders for treatment by a scale

that measures their risk for criminality in combination with their

level of drug addiction.

Criminal thinking is also a factor with women offenders, but

experts suggest that—for

women—the context is different.

First, recent studies suggest that a

relatively small percentage of

women offenders can be classified as having antisocial personality disorders. The study of

pretrial female detainees in

Chicago’s Cook County jail

found a lifetime prevalence rate

of only 14 percent for antisocial

personality according to DSMIII-R criteria (Teplin et al. 1996).

Among convicted female felons

entering prison in North

Carolina, 12 percent had a diagnosis of antisocial personality disorder, with a rate of 17 percent

for young women aged 18-24, 11

percent for women aged 25-44,

and of 2 percent for women aged

45-64. Antisocial personality disorder was highest among those

with the least education and

those from urban areas (Jordan et

al. 1996).

The experience of CSAT’s

grantees supports these statistics.

For example, the director of the

North Rehabilitation Facility says

she has found that these women

are not “sociopaths” in the commonly accepted sense. That is,

the women are not callous, narcissistic, antisocial people with no

sense of guilt, no loyalty, and no

mainstream social values.

Instead, as this CSAT grantee

points out, these are alienated

and marginalized women with

an extreme lack of self-efficacy.

The women feel so powerless

that they can’t learn from their

mistakes, because they perceive

no relationship between their

behavior and its consequences.

These self-esteem issues are frequently tied to their history of

victimization and dependence on

a male criminal partner. 

Many women do, however,

engage in such criminal behavior

as prostitution and robbery to

support their drug habits. Some

experts suggest that a woman’s

tendency toward antisocial

behavior is often based on codependency. She is not the perpetrator of a crime, but a codependent

in this behavior and this lifestyle.

Her lifestyle depends on the relationships the woman enters into,

and being dependent on a drugusing male may lead her into antisocial and criminal behavior to

please him and supply her habit.

The women need to address any

criminal thinking regarding such

behavior from the perspective of a

woman’s emotions and motives.

All the women need to look at

taking responsibility for their

own behavior and at the alternative choices they actually have.

This requires changing from an

acquiescent, passive role to a

more active, assertive one. The

CSAT grantees suggest that many

of these women have a very traditional and limited view of

women’s roles. It is important for

the women to understand that

they can, and should, take on the

responsibility for the decisions in

their lives.

The CSAT grantees report that

some subgroups of women do

have sociopathic tendencies and

attitudes similar to those found

among many male substanceabusing offenders. These subgroups include:

• Younger women (primarily in

gangs) who show violence,

criminality, and predatory

behavior; this is a disturbing

recent phenomenon. One

criminal expert suggests this

does not signify a radical

change for women. The rising

violence among women is simply proportional to the extraordinary, unprecedented level of

violence being shown today by

certain subgroups of young

males in large cities.

• Young women who have a

variety of cognitive deficits and

are developmentally very

Chapter 4—Clinical Issues in Treating Women Offenders

60

It is important for the women to understand

that they can, and should, take on the

responsibility for the decisions in their lives.
delayed. These young women

may form unhealthy emotional

attachments. As a program

director pointed out, some

young hangers-on in gangs—

actually sweet, gentle people—

can do horrible things to gain a

sense of belonging, inclusion,

and support from gang members. Because of some recent

State laws, women as young as

18 or 19 (“really adolescents,”

points out the program director) are now being incarcerated

in the criminal justice system

for drug-related offenses.

• Women whose drug addiction is

not severe, but who seem willing to commit crimes with ease

when they do use. For these

women, drug use may serve to

disinhibit their behavior and

increase their risk of crime.

• Women whose drug addiction

is not severe, but who may be

prone to criminal activity

because of their values. For

these women, criminal behavior may reflect a family systems/family values problem.

This type of problem seems

likely to be most prevalent

among women offenders from

families that have a record of

incarceration. Nearly half (47

percent) of women in State

prisons report having an

immediate family member

who has been in jail or prison

(BJS 1994). In the New Jersey

State correctional system, 75

percent of the women report

having a relative who has been

incarcerated (Gonzalez 1996).

The programming approaches.

Learning to take responsibility

for one’s own behavior and to

abide by society’s rules are two

essential elements in a treatment

program for incarcerated

women. A program needs to

have rules that are clearly stated,

understood by all the participants, and consistently applied.

The sanctions that will apply if

the rules are broken should also

be clear and consistent.

In treatment programs, sanctions are in essence “calling people out” for not going by the

rules; that is, a pre-announced

penalty is enacted when a program participant does not abide

by the rules of the program. One

example of a sanction might be

that the woman must leave a program and go back into the general prison population for a period

of time. In therapeutic communities (TCs), people may lose privileges for transgressing rules.

Generally, programs use a series

of graduated sanctions, with the

sanction becoming more severe

with each transgression.

In-Program

Sanctions and

Strategies

Programs for incarcerated

women set up their own sets of

program rules and sanctions.

These sanctions may have some

overlap with sanctions imposed

by the institution itself. Urine

testing for drugs, usually on a

random basis, is done to verify

that program participants are

remaining drug-free. This urine

testing can be done by either the

program, the institution, or both.

Typically, a positive urine results

in the imposition of sanctions.

The ideal is to work out how best

to handle such situations.

Sanctions are most effective if

they operate not as punishment

but as a trigger to motivate more

help or another step in treatment

for the woman.

Within male AOD treatment

programs, authoritatively applied

sanctions are often thought necessary to instill and reinforce a

different mind set about the

men’s antisocial behaviors. For

women, in-program sanctions

may operate somewhat differently: not as a coercive force for

change, but as a way for women

to gain personal empowerment

and responsibility. It is important

for women to feel personally

capable of judging and making

amends for their own behavior. 

The Recovery In Focus program,

a 6-month TC in Oregon, uses a

structured system of participantenforced sanctions. The In Focus

system is based on guidelines

developed at another Oregon facility, the Powder River Institution. In

Focus staff reports that many correctional officers question the

inmate-to-inmate sanction rule that

governs the In Focus treatment

community. However, the Powder

River treatment community has

had excellent results with this

method, including fewer disciplinary reports, better conduct, and

increased accountability of the

inmates. The In Focus program has

experienced similar positive results.

The system works as follows:

• Color-coded living groups. The

In Focus dormitory for program participants is divided

into four color-coded areas—

orange, blue, green, and yellow. Seven women are housed

within each color-coded section. Each color group has one

designated “Crew Chief.”

Chapter 4—Clinical Issues in Treating Women Offenders

61
• Crew Chief selection and role.

The assignment as Crew Chief

lasts for 1 month. It is an

earned position based on positive accomplishments made by

the individual woman while in

treatment. This position gives

the individual positive recognition, but also enhances her

leadership abilities. Each Crew

Chief’s job is to monitor the

other six women in her color

group. Being a “leader” is a

hard job when the person has

to interface with other women

who manifest criminal thinking errors, defiance, manipulation, and anger.

• Leadership Group for Crew

Chiefs. Every week all the

Crew Chiefs come to a support

group called the Leadership

Group. This group helps the

women to solve problems and

to gain the support of others

who are in the same position.

• Community Representatives.

Each Crew Chief is supported

by a Community Representative. These four representatives, one for each color group,

are elected by the residents of

the In Focus program, and they

may stay in this position until

they are released from the program or resign. Their primary

function is to support the particular Crew Chief and help

her remain calm, clear, rational,

and fair. To be eligible for election as a Community Representative, a woman must have

participated in the program for

30 days or more and have at

least 30 days remaining in the

program. She may not have

had any disciplinary reports

(DRs) in the last month or have

any DRs pending. If a woman

receives a DR during her

assignment as Community

Representative, she must

resign the position.

• Resident responsibilities. Each

resident in the program is

responsible for following the

rules. When a woman breaks

the rules, she must use a “threestep process” (see table 7). In

other words, the Crew Chiefs

are not expected to manage

every rule violation. Each individual is responsible for following the rules and for holding anyone they see violating the rules

accountable by using the three-step

process. The Crew Chiefs and

the Community Representatives are by no means excused

if they are rule violators. They

too will be sanctioned. 

Interventions by

CSAT-supported

Programs

The CSAT grantees have developed a wide variety of specific

program interventions to address

the women’s clinical issues. Table

8 shows the types of interventions carried out by the nine

CSAT-supported programs described in this Guide. 

In all programs, the overall mix

of interventions was designed to

ensure that the women would

receive a full range of comprehensive services, from medical

care and health risk assessment

to education and job skills training. Several of the programs also

provide extensive aftercare services once the woman offender

returns to the community. Safe

and drug-free housing after

release is particularly critical for

these women.

Chapter 4—Clinical Issues in Treating Women Offenders

62

Table 7. Recovery In Focus inmate-enforced sanctions

The three-step process

1. If an individual is breaking rules and is not in your color group,

always go to the individual first and ask that person, in a thoughtful,

caring way, to hold herself accountable.

2. If the individual is not receptive to your feedback, has an attitude, or

responds in a negative verbal way, go to the Crew Chief of her color

group and explain what has happened. Now you are to let it go and

have faith in the Crew Chief to handle the matter.

3. If the individual continues to be nonreceptive to the feedback or to

accepting the sanction, the Crew Chief will then go to a Community

Representative. The Crew Chief and the Community Representative

will then inform the individual that she must attend the Monday leadership meeting. The sanction will be stapled to the board and the

subject is then to be dropped until it can be discussed in the presence of a counselor.
Chapter 4—Clinical Issues in Treating Women Offenders

63
Chapter 4—Clinical Issues in Treating Women Offenders

64
Chapter 4—Clinical Issues in Treating Women Offenders

65
Chapter 4—Clinical Issues in Treating Women Offenders

66
Chapter 4—Clinical Issues in Treating Women Offenders

67

S

ince there is no universal

model for treating addicted women offenders, how

does a planner choose

which model to use? A

variety of possible treatment

models, therapeutic interventions, and other interventions are

widely accepted.

Selecting the

Appropriate Model

Women can recover in many

types of programs, but the goal

should be to develop a program

model designed to give the best

recovery chances to the majority

of women in the program.

According to one director, “too

many programs have just put a

dress on a male model.” Some

decisions will be based on practical realities and will depend on

such factors as:

• Average length of time available for program participation.

Pre-sentence detention centers may plan on programming for only 2 weeks, while

jail programs may be able to

offer 2- to 6-month programs

and prisons can provide longterm 6- to 18-month programs

prior to a woman’s release.

Obviously, program goals

must be tied to the time available. For example, a 2-week

prerelease program needs to

focus on motivating women

into community-based treatment and arranging for a continuum of care after release,

while a 6-month program can

undertake intensive treatment. 

• Type of model typically used in

a State and/or stipulated in

State legislation. Illinois, for

example, has a strong therapeutic community (TC) tradition, while in Washington

State, treatment programs

have traditionally been structured on 12-Step models that

do not include the strong

behavior modification component typical of TCs. (In

Washington State, the correctional institution may provide

behavioral modification components for inmates.)

• Type of women primarily being

served in the program. As one

example, the Arkansas community corrections program

serves young first-time offenders who usually return to their

families. Being removed from

their families is often a shock

and a “wake-up call” for these

young women. Their programming needs will be somewhat

different from those of more

typical prison populations,

who tend to be women offenders in their 20s and 30s with

severe and long-standing substance abuse problems, repeat

criminal justice records, and

prior treatment attempts.

• Availability of physical space.

Adequate space for treatment

programs is a problem under

the current crowded conditions in prisons and jails. An

intensive residential program

requires the space to separate

participants physically from

the general prison or jail population. The residential treatment community, usually a TC,

needs separate space large

enough for living, eating,

meetings, and program activities. Other programs need adequate space so that participants

can meet for individual and

group work in privacy.

Treatment

Modalities in

Criminal Justice

Settings

The choice of a program model

also depends on the modality—

whether a program will be outpatient, residential, or in a transitional setting. Table 3 shows the

CSAT-supported programs discussed in this Guide according to

69

Chapter 5—Program Design
their type and length of treatment. The major categories of

programs used in jails and prisons are described briefly below.

Detoxification 

Detoxification is an important

first step in the treatment of substance abuse for women who are

experiencing acute effects from

drugs or alcohol. This first step

involves stabilizing the person

and managing withdrawal symptoms while toxic substances are

eliminated from the body.

Although most larger jails provide detoxification, nonviolent

offenders are often referred to

community agencies for these

services (Peters 1993). The Task

Force on the Female Offender,

convened by the American

Correctional Association (ACA),

recommended that separate

detoxification units be established in local facilities for female

offenders (ACA 1990, p. 42).

These units should provide for

detoxification, medical and mental health screening, counseling,

and community referrals as part

of the booking and intake

process. 

Although methadone is most

commonly used to detoxify individuals from opiates in the community, methadone is rarely used

in prison settings. Some correctional systems force offenders to

detoxify “cold turkey”—a practice that is dangerous with pregnant women because it can harm

or kill a fetus. According to

CSAT’s Treatment Improvement

Protocol (TIP 2) on pregnant,

substance using women, clonidine has also been used effectively for detoxification, but its safety

for pregnant women is not

known (CSAT 1993b). TIP 2 suggests that agents that may be

used to reduce extreme agitation

during withdrawal among pregnant cocaine addicts include low

doses of diazepam (Valium),

chlordiazepoxide (Librium),

desipramine (Norpramin), doxepin (Sinequan), and phenobarbital. Another useful CSAT TIP is

No. 19, Detoxification from Alcohol

and Other Drugs. 

* * * * * *

CSAT TIPs are available through

the National Clearinghouse for

Alcohol and Drug Information.

See “Drug-Related Federal Clearinghouses” in the Resource List.

* * * * * *

Drug Education

Drug education should not be

considered treatment, but it can

be an effective tool to inform

inmates about alcohol and other

drug issues. Some prisons provide drug education for their

general populations, but only 14

percent of jails provide such

services, according to a recent

survey (Peters et al. 1992). At

times, women offenders may

attend drug education classes

while waiting for an opening in a

drug treatment program. In some

cases, drug education may cause

a woman to recognize that she

has a drug problem and needs to

become involved in treatment.

Drug education may also be

useful at an early stage in a jail or

prison substance abuse treatment

program. In this case, the content

would focus on developing the

woman’s motivation for treatment and encouraging her to

remain in treatment.

Outpatient Treatment 

Outpatient treatment can be

either standard or intensive. In a

jail or prison setting, inmates

involved in outpatient treatment

live in the general population and

work and interact with other

inmates. However, the preferable

situation for those in intensive outpatient programs is to be segregated from the general population.

• Standard outpatient programs.

In standard outpatient programs, the women typically

receive services about three

times per week, including

group therapy once or twice a

week and individual counseling about once a week. The

kind of topics covered would

be an introduction to the 12-

Step model, identifying triggers to relapse, and counseling

on HIV/AIDS prevention.

These low-intensity programs

are suitable for women who

typically have a short history

of substance abuse, have had

minimum to moderate drug

use prior to incarceration, and

have relatively strong motivation or support for recovery.

None of the CSAT-supported

women’s models described in

this Guide are low-intensity

outpatient models.

• Intensive outpatient programs.

Intensive outpatient services

are in-custody treatment that is

part of a continuum of care

and is adjacent to a community

aftercare component. Intensive

outpatient programs are

appropriate for women with

longer and more severe drug

Chapter 5—Program Design

70
abuse histories, who are likely

to have had previous treatment

and may also be recidivists. The

programs are effective for

incarcerated women or for

women in detention centers

who may be released into the

community instead of being

incarcerated. Women receive

services for a minimum of 3 to 5

hours per day, three to five

times per week.

In this type of program, the

women receive a variety of

diagnostic, clinical, didactic,

and counseling services.

Motivating women to enter

residential or outpatient treatment in the community after

their release is a major goal.

Treatment is most effective just

prior to the woman’s release

date.

Two of the programs described in this Guide are intensive outpatient programs—the

Incarcerated Women’s Recovery Program at North Rehabilitation Facility and the Baltimore Detention Center program. Services provided at

North Rehabilitation Facility

include group counseling for

substance abuse, chemical

dependency education, relapse

prevention, 12-Step groups,

anger management, STD testing and treatment, family

counseling, adult basic education and GED testing, general

medical services, acupuncture,

mental health counseling, and

assistance with housing. 

Residential Treatment 

Residential programs in prisons

and jails refer to programs where

the participants live together in a

facility separate from the general

prison population. The level of

substance abuse treatment can

vary in intensity. For example,

Forever Free, at the California

Institution for Women, provides

alcohol and other drug (AOD)

treatment for 20 hours per week

over a minimum of 6 months;

participants also spend at least 20

hours per week on work assignments with the rest of the prison

population.

Therapeutic communities

(TCs), which are the most common residential modality in

prison and jail settings, offer the

most intensive level of programming available. The participants

live and eat together without

mingling with the general population and they spend full work

days in their AOD treatment program. Women appropriate for TC

treatment will have a longer history of substance abuse than

those in less intensive programs,

will often have had repeated

failed attempts at treatment, will

have used high levels of multiple

drugs prior to incarceration, and

will continue to have chronic or

severe use despite adverse consequences. Like intensive outpatient programs, TCs are most

effective just before the woman is

released from custody, so treatment needs to be scheduled in

tandem with a woman’s release

date. The types of TC programs

in criminal justice institutions

may be categorized as follows:

• Traditional 9-18 month TC

programs. The traditional

long-term model TC is an

appropriate model for prisons, where sentences are at

least a year in length. The

WCI Village TC in Delaware,

where participants’ length of

stay ranges from 6 to 18

months, fits this model.

• Modified 3-12 month TC programs. This shorter TC model

is also appropriate for prison

populations. The CHOICES

community punishment facility in Arkansas operates a coeducational program where

the length of stay varies from a

minimum of 90 days to 24

months. The Recovery In

Focus program at the Oregon

Women’s Correctional Center,

Salem, is a 6-month pre-release

day treatment program. This

program has a special focus on

family and life skills, with a

goal to reunite women with

their children.

• Short-term 2-6 month TC programs. Short-term TCs can be

used in correctional settings

where sentences are of shorter

length. Among the CSAT

grantees, there are three shortterm women’s TCs. The

longest is the OPTIONS county jail system program in

Philadelphia, where women

Chapter 5—Program Design

71

Therapeutic communities, which are the most

common residential modality in prison and jail

settings, offer the most intensive level

of programming available.
Chapter 5—Program Design

72

stay an average of 6 months.

Two are 2-month programs—

the SISTER jail program in San

Francisco and the Stepping

Out jail project in San Diego. 

As the OPTIONS director

points out, the length of a program is not as important as the

program’s process and support

for healing. Rather than “residential treatment,” it may be

more appropriate to call such

supportive programs a “therapeutic center ” or a “therapeutic

living environment.”

After their release into the

community, some women will

enter community residential

treatment programs. These residential rehabilitation programs

require full-time participation in

treatment activities and programs. Table 9 shows a chart

matching type of treatment to

appropriate populations.

Transitional Programs

Several types of facilities may be

available for women in their transition back to the community.

Some of the more common

include work-release centers, day

treatment programs (sometimes

called day reporting centers), and

halfway houses. These types of

transitional facilities are described in chapter 6 in “Various

Paths for Women Upon Release.”

Types of

Approaches and

Program

Components

For treating women’s addiction,

the CSAT grantees emphasize

how important it is to use a combination of methods. Even the

shorter programs use varied

techniques. 

* * * * * *

Training materials that may be

helpful for program designers

are listed in the Resource List.

Some of these materials, such as

new training materials by

Stephanie Covington, “Helping

Women in the Criminal Justice

System,” may be useful for all

types of alcohol and drug (AOD)

treatment programs.

* * * * * *

Stepping Out, a program for

inmates with a minimum of 50

days remaining to serve, expects

in that short time period to give

women an introduction to treatment concepts, knowledge about

what to expect in long-term treatment, and a level of comfort with

the treatment process. The program uses a combination of TC

principles, 12-Step principles,

and cognitive therapy. This program finds that, for some

women, the combination of cognitive therapy—to understand

why the woman uses drugs—

plus behavior modification is a

better option than 12-Step programs. Following are some of the

major types of interventions and

approaches used by CSAT

grantees for women offenders

with substance abuse problems.

Psychoeducation

Psychoeducational approaches

are frequently used in treating

jail inmates who are incarcerated

for relatively brief periods of

time, often using “closed” groups

of inmates who enter and leave

at the same time. Program staff

may include professional counselors and ex-addicts. This

approach is based on the premise

that substance abuse disorders

develop as a result of multiple

biopsychosocial factors. The goal

is to help individuals recognize

their own individual predisposition to substance use, their personal risk factors, and to develop

coping skills and strategies to

enable them to attain long-term

abstinence. Program components

usually include (1) developing

motivation and commitment

through understanding addiction history, stages of recovery,

and the adverse effects of addiction on all phases of life; (2)

enhancing life and communication skills; (3) education to prevent HIV infection; (4) relapse

prevention skills, including identification of relapse triggers and

strategies to manage lapses; and

(5) developing an individualized

aftercare plan. The longer programs supplement the psychoeducational material with a range of

adjunct activities, such as mutual-help groups, GED classes,

vocational training, mental

health counseling, and work

assignments.

Psychoeducational approaches

have primarily been used with

male inmates, so the approach

needs to be modified for women.

The primary didactic practices—

lectures, group exercises, homework, and instructional materials—need to be augmented with

a focus on process groups that

discuss women’s issues, as well as

individual and group counseling.

A fundamental clinical service for

effective women’s treatment is

widely recognized to be the
Chapter 5—Program Design

73

Substance-abusing

offender subgroups Self-Help Educational Outpatient

Intensive

outpatient

Residential

TC

Transition/case

management

+ / –

(need for

structure,

conditions,

sanctions)

+ / –

(focus on

cause-effect)

– – + +

+ / – + 

(careful

screening)

+ / – – + / –

(screening,

special

services)

+

+ + / – – + + +

+ + + + / – + / – +

Criminogenic

Co-occurring

disorders

Addict

Early stage

Code:

Co-occurring disorders—Individual with mental illness and substance abuse problems

TC—Therapeutic community

+ Highly effective

+ / – Somewhat effective

– Minimally effective

Table 9. Matching substance-abusing offender subgroups to treatment models

Adapted from: Bureau of Justice Assistance, Design and Implementation Issues for Drug Treatment in the Jail Setting.

Washington, DC: U.S. Department of Justice, 1991.
women-only counseling or therapy group. These groups need to

focus on the issues that are the

source of enormous emotional

pain for women, such as sexuality

and sexual behavior; incest, rape,

and other sexual abuse; family

violence; and relationships with

alcohol and drug-using partners,

spouses, parents, and other family members. Motivation to treatment—using a really positive,

upbeat approach—is needed to

buoy up the participants and to

promote optimism and the desire

to be involved in communitybased treatment after release.

Pharmacological

Treatment

Methadone treatment has been

researched extensively and has

been shown to be effective in

reducing withdrawal symptoms

and drug cravings for opiatedependent patients (Anglin and

Hser 1990). The most recent

major study—a follow-up of

3,000 clients 1 year after drug

abuse treatment conducted by

the National Institute on Drug

Abuse (NIDA)—found that 69

percent of outpatient methadone

clients had effectively reduced

their heroin use and 48 percent

had reduced their cocaine use

(Hubbard et al. 1997). Illegal

activity declined by 52 percent,

while the number of clients jailed

dropped from 63 percent in the

year before treatment to 21 percent in the year after treatment.

In this Drug Abuse Treatment

Outcome Study (DATOS), 39 percent of patients admitted to the

outpatient methadone programs

were women.

Methadone treatment is usually used for people who have not

been able to achieve abstinence

in drug-free programs. Methadone is used infrequently in jail

settings, partly because administrators are reluctant to provide

narcotics to inmates and because

of concerns regarding medical

supervision and institutional

security (Magura et al. 1992). In

1997, a National Institutes of

Health Consensus Development

Panel on effective medical treatment of heroin addiction recommended that all opiate-addicted

persons under U.S. legal supervision have access to methadone

maintenance treatment (NIH

1997). According to testimony at

that conference, only one U.S.

prison currently provides methadone treatment for inmates.

Methadone treatment is an

important intervention for pregnant women offenders who are

addicted to opiates. Detoxification from opiates is a danger to

the unborn fetus. For this reason,

CSAT TIP No. 2, Pregnant,

Substance-Using Women (CSAT

1993b) recommends methadone

maintenance for pregnant opioid

users. Pregnant women are usually the only population eligible

for methadone maintenance in

U.S. jails and prisons.

Psychosocial Treatment

Psychosocial treatment includes

an array of techniques, including

role plays and psychological

counseling that may involve the

client and her children and significant others. The short-term

Baltimore detention center program, for example, is designed to

provide intense, short-term psychosocial rehabilitation services,

mostly in a group setting. The

program uses a combination educational, skills building, and

motivational model. The women

participate in group therapy sessions to process women’s issues

and have individual counseling

sessions with a therapist. In addition, the educational groups use

a cognitive/behavioral substance

abuse treatment curriculum that

focuses on developing relapse

prevention skills (Mattson 1995).

Topics covered include anger

management, assertive communication, drug refusal skills, and

daily planning.

Important components include:

• Individual/group counseling

and targeted counseling.

Women offenders respond

well to both guidance and

counseling (ACA 1990, p. 43).

Some of the issues that therapy

groups may address include

family issues, incest, domestic

violence, prostitution and survival sex, and shoplifting. For

those with HIV/AIDS, individual counseling, group therapy,

and peer support groups with

other HIV-positive women are

all appropriate interventions.

Depression, sexual abuse, and

physical abuse are so prevalent

among this population that

these issues are often treated as

an underlying theme in all the

work, rather than as special

group topics.

• Interactive process groups.

Process-oriented groups, led

by either peers or staff, create a

sense of connection among the

participants. The research suggests that connectedness with

others is critical to women’s

growth and development, and

Chapter 5—Program Design

74
that substance-abusing women

may lack this sense of connection. Interactive process

groups, which help women

develop this sense of connection and relatedness to each

other, are therefore an important and therapeutic approach

for women.

• Emotional healing. The women

need to understand their feelings and work through their

emotions. Because women

often report that they became

dependent on drugs in order

to seek relief from painful emotional states, it is imperative

that there be an emphasis on

affect as well as cognitive

work. The CSAT-supported TC

models take advantage of a

wide variety of peer and group

therapy techniques.

WCI Village, for example,

uses transactional analysis,

psychodrama, and branch

groups—a type of group in

which clients meet regularly to

share in-depth thoughts and

feelings as a basis for understanding themselves and

developing better coping skills

(Inciardi 1996). The Recovery

In Focus program uses such

methods as transactional

analysis, gestalt therapy, and

role plays. 

Nontraditional Therapies

Acupuncture, meditation, yoga,

stress management, relaxation

techniques—these therapies are

important because all help the

women “own” their own recuperative efforts. Many AOD

treatment programs report that

acupuncture helps their clients in

the early stages of withdrawal

and recovery. Acupuncture has

been used in treating various

types of drug abuse, including

alcohol, heroin, methadone, barbiturates, diazepam, phencyclidine (PCP), cocaine, and nicotine.

Unfortunately, research on

acupuncture for drug treatment

is sparse and there are only isolated reports of well-controlled

clinical trials.

Three of the programs

described in this Guide—the SISTER project, Baltimore Detention

Center, and North Rehabilitation

Facility—use acupuncture up to

five times per week. One of these

program directors states that,

after acupuncture, most clients

report experiencing an overall

sensation of relaxation and peace

of mind that lasts approximately

24 hours. This program suggests

that acupuncture be repeated

with consistency during the first

10 days and then be gradually

reduced.

Criminal Thinking

Interventions 

Some addicted women offenders, like men, have long-standing

criminal thinking patterns and

values. Cognitive therapy is used

to help women recognize errors

and fallacies in their thinking.

The women tend to be manipulative, and often see their criminal

behavior as the result of drug use

to which the individual has fallen

victim (Yochelson and Samenow

1986). To change behavior, the

person’s underlying beliefs and

value systems must also be

changed. Treatment interventions designed for women are at

an early stage of development.

Some of the CSAT program directors have used materials developed by Koerner, Fawcett, Inc.

and by Gorski and Miller (1988).

(For more information about

materials and available training,

see the Resource List.)

These criminal thinking materials can usually fit into any program design. Research suggests

that criminal thinking patterns

are the same for both men and

women. However, the context of

women’s lives, including the

very real victimization that many

women offenders experience,

needs to be addressed. Some of

these materials are designed to

start from the women’s existing

beliefs and values, to help them

understand their own aberrant

thinking, and then to open up

their minds to new information

and a change in beliefs.

In the criminal thinking construct, for women the crime itself

may be immaterial; it is the circumstances that matter. Women’s

crimes are often done in conjunction with men, so it is important

for a woman to look at her relationships prior to the crime. The

In Focus program looks at

women-specific thinking errors

Chapter 5—Program Design

75

Cognitive therapy is used to help women recognize

errors and fallacies in their thinking.
Chapter 5—Program Design

76

in such areas as prostitution, low

self-worth, relationship addiction, and codependence.

Preventing Relapse and

Recidivism 

Relapse prevention components

are a critical element in programs

treating substance-abusing

women offenders. Relapse to

substance use is a common problem for all recovering individuals—this is one of the symptoms

of alcohol and drug dependence.

Offenders are particularly vulnerable to relapse during the initial period after their return to

the community (Peters 1993).

Substance abuse is often a

method of coping with stress,

and the stress is very high for

offenders as they leave a structured setting for life outside the

institution.

The research points to the

value of drug treatment in preventing criminal recidivism. The

findings show that successfully

reducing drug use does dramatically reduce further criminality.

For example, follow-up studies of

career addicts in Baltimore have

found high rates of criminality

among heroin users during those

periods when the users are

addicted and markedly lower

rates during periods of nonaddiction (Inciardi et al. 1993a). 

Clearly, reducing relapse to

alcohol and drug use is critical for

reducing recidivism. For women

offenders, relapse prevention

needs to be broad in scope. Some

of the factors implicated in

relapse for women are mental illness, including depression, bipolar disorder, and post-traumatic

stress disorder resulting from

physical and mental abuse.

Another key factor in relapse for

women offenders is that most

lack the skills to cope with the

stressful situations in which they

live. Their relationships are central: when their primary attachments—whether mother and

siblings or male partner—are

part of the drug-using scene,

women may need to make the

difficult choice of divorcing

themselves from these attachments. To avoid relapse, many of

these women must build completely new lives, with new

sources of support in the community.

Several relapse prevention

approaches have been designed

specifically for criminal justice

populations. The materials used

by the CSAT-supported women’s

programs described in this Guide

are in the Resource List under

“Program Materials.” Relapse

prevention approaches help

offenders recognize their own

“triggers” to relapse and develop

the skills needed to prevent

relapse. Such skills include strategies to recognize and handle the

individual’s recurrent thoughts,

cravings, or physical desires to

use drugs; strategies to deal with

positive expectations about the

initial effects of drug use; and

strategies to monitor the

woman’s relapse warning signs,

to handle high-risk situations, to

build drug-free friendships, and

to adopt a more balanced lifestyle

(Peters 1993).

Important

Programmatic

Factors

Certain key factors need to be

built into any treatment program

for substance-abusing women

offenders, regardless of the type

of program model used. These

are elements that the research

has shown are important for the

recovery of offenders who have

severe, long-term patterns of

substance abuse. These elements

include providing longer time in

treatment, a graduated series of

intermediate sanctions through

the criminal justice system, clear

sanctions and rules within the

treatment program, comprehensive services, and a continuum of

care after release.

Length of Time in

Treatment

For both men and women

offenders with drug problems,

spending longer lengths of time

in treatment is a critical factor in

preventing recidivism. Repeated

research demonstrates that the

Relapse prevention approaches help offenders

recognize their own “triggers” to relapse and

develop the skills needed to prevent relapse.
longer a substance-abusing

offender stays in treatment,

whether that treatment is in a TC

or outpatient facility, the better

the outcome in terms of declines

in drug use and criminality (De

Leon 1984; Anglin and Hser 1990;

Hubbard et al. 1989). Statistics

from the CSAT women’s programs demonstrate the important effects of time in institutional treatment, combined with

community aftercare following

release. Findings include:

• Only 30 percent of women who

completed the Recovery In

Focus prison program had a

new subsequent arrest, compared with 44 percent of those

who did not complete the program and 65 percent among

those who did not participate in

the program at all (see page 147).

• Some 90 percent of Forever Free

graduates who subsequently

stayed for 5 months or longer in

community residential treatment programs were successful

on parole, compared with 38

percent of program dropouts

and 62 percent of program

graduates (see page 147).

• Among participants in both the

SISTERS and the Stepping Out

jail TC programs, those who

continued into community

aftercare after release were significantly less likely to be

arrested (see pages 148-149).

• Stepping Out graduates provided only with aftercare

stayed in treatment an average

of 33 days; those receiving

aftercare plus safe and sober

housing stayed in treatment

for more than 80 days—more

than double the time for aftercare alone (see page 149).

Coordinating With the

Criminal Justice System

Offenders in treatment programs

often do better, remaining longer

in treatment, when the treatment

is mandated and coordinated as

an intermediate sanction within

the criminal justice system.

Treatment can be constructively

used as one sanction within a

graduated series of intermediate

sanctions. In an increasing number of jurisdictions, the courts, correctional system, and treatment

programs are being coordinated to

provide this kind of synergy. In

Baltimore, for example, the judges

and detention center officials are

all committed to rehabilitation for

addicted women and are attempting to match women with appropriate treatment services. Coordinating treatment with sanctions

takes communication, and often

training for all personnel

involved. The CSAT grantees suggest that certain types of coordinated actions are important,

including the following:

• Judges need to be encouraged

to refer addicted offenders to

treatment, but the particular

type of treatment should not

be specified; that should be

determined by the screening

and assessment process.

• The sentencing to treatment

should be time-neutral. That is,

because of treatment, the

length of the sentence should

not be extended beyond the

normal length for that offense.

Offenders should not be kept

on waiting lists for treatment

while in custody, so that the

treatment actually extends

their time in custody.

• Sentencing needs to be tied

into the successful completion

of treatment phases so that, as

a woman completes her in-custody treatment program, she is

allowed to start the post-custody release and treatment

phase immediately. Creating a

hiatus in her treatment, with a

return to the general population, may cause the woman to

regress and lose ground.

• A series of graduated sanctions

is most effective for ensuring

that women stay in treatment

after their release. In some programs described in this Guide, a

program graduate is allowed to

leave the prison or jail only if

she will be participating in

treatment or in a treatment

plus work release program.

Less restrictive measures than

incarceration, such as house

arrest or electronic monitoring,

would seem to offer promise as a

method of supervising women in

the community. However, these

types of options have not been

relevant for the CSAT-supported

programs, which are based in

facilities. For example, both

house arrest and electronic monitoring are available in Baltimore,

but these options are not directly

relevant to the facility-based

Baltimore pretrial program.

Coordinating Program

Rules and Institutional

Sanctions 

Learning to be personally

accountable is a major component of all the CSAT-supported

women’s programs. Rules form

the backbone of a program. The

program’s rules will be an additional layer on top of the jail or

Chapter 5—Program Design

77
prison’s rules and sanctions.

How the institution’s rules and

the program rules will mesh

needs to be worked out individually for each program.

The issue of urinalysis is one

important sanction to be considered. There is no one answer to

this. Staff of each program must

decide whether to collect urines,

and if so, what the consequences

will be for a “dirty urine.” Among

the CSAT women’s prison programs, urines are collected by the

institutions in some cases, by the

programs in others, and by both

in one case. CSAT’s expert panel

on women’s programming suggested that important factors to

consider include the following: 

• Effect of use on others in the

program. In a short-term,

intensive program, drug use

by one participant could contaminate the program for the

others. The 2-week program at

the Baltimore detention center

does urinalysis for therapeutic

reasons. If a woman uses, she is

out of the program. However,

results are coded so that the jail

authorities do not know which

participant tests positive. In a

longer term community program, it would be possible to

work with a woman, to allow a

new attempt, without jeopardizing the recovery of others.

• Tolerance level of the institution. In correctional settings,

there will be zero tolerance for

drug use. If the institution does

the urinalysis, the institution

will set the punishment. At the

SISTER project, for example,

the sheriff’s department does

the urinalysis; a woman with a

drug-positive urine test will

receive 5 days in the lockup or

could have her prison time

extended.

• Treatment program policies.

The longer term TCs try to

be flexible about readmitting

a woman who has had a

drug-positive urine test. In

the SISTER project, on an

individual basis, a woman

may be permitted to return

to the treatment program.

However, she must first

demonstrate her commitment by attending substance

abuse support groups in

another housing unit. At

WCI Village, women are

removed from the program

for 90 days and then return

to the program.

The experience of the CSATsupported programs is that very

few women test positive for psychoactive drugs while in the programs. For example, in over 2

years of program operation at the

Baltimore detention center, only

one woman has tested positive.

Continued collecting of urines

during the post-release period is

done in some jurisdictions as part

of a continuum of graduated

sanctions. For example, in the

Delaware three-stage system of

custody, work release, and aftercare, urine monitoring continues

for 6 months in the aftercare

phase. 

Provision of

Comprehensive Services

As the earlier chapters make

clear, the vast majority of female

offenders with drug abuse problems have multiple and longstanding psychosocial problems.

Substance-abusing offenders

often exhibit some form of cognitive problem, psychological

dysfunction, unrealistic or disorganized thinking, misshapen

values, and frequent deficits in

educational and employment

skills (Inciardi and Scarpitti

1992). For these individuals,

drug abuse may be complicated

by social and psychological

problems. Thus, the goal of treatment is “habilitation”—which

involves socializing the person

for the first time into a responsible way of life, rather than rehabilitation—which implies the

return to a previous way of life.

CSAT recommends that treatment programs for incarcerated

women provide interventions in

the clinical areas discussed in

chapter 4. In addition, there are

two important areas of programming that need to be available for

women offenders, either through

the criminal justice system or

community programs. These

areas pertain to higher education

and vocational training.

Education

Incarcerated women tend to be

very eager to take advantage of

education and other programming. During one study of jail

programming for women, a jail

Chapter 5—Program Design

78

Incarcerated women tend to be very eager to take

advantage of education and other programming.
manager observed that women

in his jail, unlike many of the

men he had supervised in other

facilities, were “very receptive to

learning, improvement, and a

variety of programming opportunities” (Gray et al. 1995). In this

study, inmates rated work training as the single most needed

program, followed by college

courses, ranked third, and vocational courses, which tied for

fourth. The chance to take college

courses is particularly important

for women who have enough

prerequisites. 

Vocational Skills Training

Economic self-sufficiency is a cornerstone to success after imprisonment. Undereducated women

have a particularly tough time in

the job market, because there are

virtually no traditionally female

jobs that pay well for unskilled or

semiskilled labor. Treatment programs for women offenders need

to take whatever actions they can

to expand vocational opportunities. There are two problem

areas: 

• Opportunities for training in

the better paying male jobs are

not made available. A 1980

General Accounting Office

study found that, within the

Bureau of Prisons, women had

access to only 13 prison industry jobs while men had access

to 84 (Miller 1990). Work programs for women are sexstereotyped, with much emphasis on cosmetology, clerical

skills, and food service (Glick

and Neto 1982, pp. 141-154).

• Prison security needs for

women can limit their opportunities. At coed institutions,

security needs (such as requiring a guard to take the woman

to and from a program) can

severely restrict the number of

job training opportunities for

women. 

Although various nontraditional women’s vocational programs are being increasingly

introduced into women’s prisons

(Owen and Horwitz 1991), the

CSAT demonstration projects

found their women had very limited access to vocational training

opportunities. As one CSAT program director pointed out, many

of these women clients do not

have skills that suit them for

office work—which is what the

training programs for women

tend to emphasize. Women can

benefit from training in nontraditional work that pays well—such

as welding, auto body repair,

auto mechanics, electrical work,

bricklaying, and computer maintenance.

An additional caveat is important. The division of time

between a woman offender’s

work and her substance abuse

treatment can be a problem.

Women who have severe and

long-standing addiction problems need to be focusing full time

on their treatment. This can create scheduling tensions with the

criminal justice institution. In two

of the CSAT-supported prison

treatment programs, women

were initially required to work for

8 hours per day. This meant the

treatment had to be sandwiched

into early morning hours and

then into the evening, when the

women were exhausted. It is far

preferable for the women’s time

in treatment to count toward the

work requirement.

Continuum of Care

In-prison treatment programs for

incarcerated women are not sufficient for most of this population. It is essential that the

women receive a continuum of

care that extends to community

treatment and other support

after their release. As one prison

AOD program director put it,

“The majority of women who

leave the institution ‘cold turkey’

need further help. If they don’t

get it, most of them will be back

inside within a month.”

The goal should be to extend

supervision and treatment until

the woman is in full recovery,

with a safe, drug-free place to

live, a support system in place,

and the means for self-sufficiency. For prison and jail AOD programs, “time in treatment” needs

to encompass the whole continuum of care, not just the institutional segment.

* * * * * *

Chapter 6 describes the many

strategies used by the CSAT

grantees to provide this continuum of care for their women

clients. 

* * * * * *

Just how managed care may

affect this continuum of care for

ex-offenders is not now known.

Many States are now moving

toward managed care plans as a

way of managing their publicly

funded AOD clients. Offenders

returning to the community generally receive any treatment

through the publicly funded

providers. Managed care plans

usually limit the number of AOD

treatment sessions that a client

Chapter 5—Program Design

79
may receive, often in terms of

both annual and lifetime benefits. Ex-offenders are likely to

need more intensive treatment

for longer periods than the standards allowed by their State’s

managed care plan.

Adapting Models

to Women’s Needs

Traditional models for treating

substance abuse were all

designed for men. Because

women’s addiction is different

from men’s, women need models

adapted to their psychology and

addressing the causes of their

substance abuse. The accumulated experience in women-specific

programs is making this task easier than in the past.

Recommendations of

CSAT Women’s Programs 

In setting up a model specifically

for women offenders, the CSAT

women’s prison programs offer

the following recommendations:

• Use a woman-centered model

and staff approach. Look carefully at the underlying

assumptions of the basic

model, and adjust the curriculum and design to match

women’s psychology and

developmental needs. Just

adding women-specific topics

to a male model program does

not do enough. The fact that

women counselors are used

also does not guarantee a

woman-centered approach,

since their work experience

may be with the more typical

male-oriented models (New

York State Division of Alcohol

Abuse and Alcoholism 1990).

• Use a model matched to the population being served. Look at

the population to be served,

construct a model that incorporates the latest thinking

about women’s emotional

development and addiction,

and build a program that

meshes with the needs of that

population. A rehabilitation

model is appropriate when

addiction is seen as just one

piece in a constellation of

biopsychosocial problems.

Other models are possible,

depending on the population

being served and the program’s basic theory about

addiction. Examples would be:

(1) for young women, an adolescent developmental model

emphasizing tasks in developmental growth could be appropriate; (2) when addiction is

seen as a primary disease, then

a model that stresses spirituality and how to overcome craving may be appropriate (e.g., a

12-Step model); and (3) if

lifestyle is seen as the driving

problem, then a resocialization

model, such as a TC model, is

appropriate.

• Use a stages-of-change model.

Based on the addiction theory

chosen, then a stages-ofchange model needs to be

adopted and staff need to be

trained to understand and use

it. (See, for example, Miller and

Hester [1986], Gorski [1991],

and Prochaska and DiClemente

[1986].) The stages-of-change

concept then undergirds the

program, as staff continue to

assess each woman and develop individual treatment plans

according to where each

woman is on the continuum of

awareness, motivation to

change, and readiness to take

positive action. The Prochaska

and DiClemente model, recommended by one of the CSAT

grantees, involves six stages: (1)

precontemplation (the person

sees no need to curtail the

habit), (2) contemplation (the

person sees the negative results

of addiction), (3) determination

(the person begins to examine

the best treatment methods), (4)

action (the trial with abstinence

begins), (5) maintenance (the

focus shifts to relapse prevention), and (6) termination (the

person is in stable, long-term

recovery) (Prochaska 1996).

• Build in a premotivation stage.

Build in a premotivation

process. Treatment starts under

artificial circumstances in a

custody setting. In the community, a long process of motivation often occurs before people

voluntarily enter treatment or

mutual-help support groups.

Women offenders frequently

need rehabilitative work,

focused on issues underlying

their addiction, before they can

commit to their recovery. The

North Rehabilitation Facility in

Seattle recommends three initial process goals for women

during this pre-readiness

phase:

(1) To develop some meaningful awareness of the

addiction problem, based

on their own values.

(2) To resolve their feelings of

ambivalence about substance use, and to develop some intrinsic motivation to change.

Chapter 5—Program Design

80
(3) To take some positive

action. 

• Plan for cultural and ethnic

diversity. Look at the racial and

ethnic mix of the program population and plan to provide

appropriate, sensitive programming (and staff) for special groups.

• Develop flexible programming.

Provide as much program flexibility as possible to meet varying needs of the women.

Research and experience show

that women want and do better with an individualized

response to their problems. In

addition, because of their

greater numbers, male offenders tend to have more varied

treatment programming available to them. Programs for

women, because there are

fewer of them, need to be flexible enough to serve a range of

clients. 

Modifying the

Common Male

Treatment Models 

The two most widely used treatment models for incarcerated men

and women are those based on 12-

Step principles and therapeutic

communities (TCs). As these models have evolved, current criminal

justice treatment programs tend to

blend philosophies; for example,

many prison TCs incorporate 12-

Step principles.

The underlying reason why

both these models need adaptation for women is the same: both

models were initially developed

for men. Before planning a program for women, it is important

to look at the basic assumptions

underlying these male-oriented

models and adapt them to be

more effective for women.

Essentially, both the 12-Step and

TC models operate on assumptions about male power, as perceived by male clients. Both

models offer powerful features,

particularly when adapted to

meet the needs of women. 

The 12-Step Model

Alcoholics Anonymous (AA), the

original 12-Step model, was

founded in 1935 and was initially

designed for men. As late as 1968,

only 22 percent of AA members

were female. During the 1970s

and 1980s, the number of women

in AA mushroomed and womenonly groups spread across the

country. By 1992, at least 35 percent of all AA members were

women. According to Covington

(1991b):

It is impossible to describe

the variety of AA meetings

and members that exist at

this time. There are specialized meetings for women,

lesbians, Native Americans,

nurses, non-smokers, people

who are HIV-positive, and

scores of others who may

share some other characteristic in addition to their

desire to stop drinking.

At the time AA was founded, it

represented several radical concepts (Covington, in press). The

12-Step programs are free, they

are nonhierarchical, and they are

spiritual in a nonspiritual society.

There is still no involvement by

professionals or experts in 12-

Step groups. Twelve-step groups

stress face-to-face interactions

and encourage their members to

accept personal responsibility for

themselves. Members receive

social support and a sense of connection to others through the creation of a caring community.

Today, the 12-Step AA model is

a basic component in nearly all

treatment for offenders—particularly the ongoing groups that

offer peer support in institutions

and in the community after

release. All the CSAT-supported

programs described in this Guide

have 12-Step study groups. The

North Rehabilitation Facility uses

an AA model modified for

women for its program design.

Those designing their programs on an AA model need to be

aware of its major advantages,

and its limitations, as a model for

healing women offenders. The

AA principles work well for

women—but the language and

principles need to be interpreted

in ways appropriate for women.

Among the 12-Step principles

that are important for women’s

healing are the steps to restore

the person’s sense of integrity

and belief in self and to help her

atone, using bonding, fellowship,

and sharing with others.

In designing a model for

women offenders, these modifications are important:

Chapter 5—Program Design

81

Those designing their programs on an AA model

need to be aware of its major advantages, and its

limitations, as a model for healing women offenders.
• Expand the early interpretation of the 12-Step disease

model, in which alcoholism is

perceived as a primary disease

of the individual. Chapter 2

explains how many practitioners today perceive the medical

model of disease in a broader

holistic context, taking into

consideration such issues as

genetic vulnerability, environmental influences, and lifestyle

choices.

• Adapt and reinterpret the language of some of the literature,

which was written as much as

50 years ago, to eliminate

overtly sexist content and connotations. A Woman’s Way

Through the Twelve Steps

(Covington 1994) is particularly helpful in illustrating the

numerous ways in which

women may individually interpret and learn from the 12

Steps. 

• Develop a premotivation component. Programs based on

variations of the 12-Step model

tend to start at the point of

motivation to treatment, after

ambivalence about substance

use has been resolved. The

focus is on moving toward

recovery. Models designed for

women offenders need to step

back to a prior phase. The

model should assume the

woman is not initially motivated to stop her substance abuse

and that the program needs to

help the woman acquire the

motivation she needs for

change to occur. Motivation

requires introspection, a sense

of self-efficacy, and a sense of

self. A lot of work goes on

before a person becomes motivated into treatment. Programs

that don’t help women go

through these initial steps may

just be “skimming off ” and

reaching only those women

who have already done the

hard work of motivation on

their own.

Those designing women’s

programs need to be aware of

the body of feminist literature

that critiques the 12 Steps and

criticizes their language as

being simplistic, sexist, and

reductionist (Bepko 1991;

Berenson 1991; Kasl 1992; and

Rapping 1996). Feminists are

particularly concerned about

the 12 Steps emphasis on powerlessness and on the call for

“submission,” which some

feminists confuse with surrender. The concern is that the 12

Steps may demand giving up

control and power over one’s

life and encourage submission—neither of which would

be productive for women.

It is important to keep in

mind the dynamic operating

with female offenders. These

women have not felt social

pressures to achieve control

and dominance, as men have.

Their experience often is to be

profoundly violated as people,

to be subjected to physical and

sexual abuse, to lack personal

boundaries. These women feel

powerless over almost everything in their lives. For marginalized women, the recovery

process is different than for

men. These women need to

acquire control. They need to

recognize and be responsible

for their own personal boundaries and to gain a sense of self

and of their own identity as

individuals.

At this point, there is also a

considerable body of helpful literature from people who have

successfully adapted the 12 Steps

in work with substance-abusing

women. They point out that the

masculine “power over” is what

the 12 Steps ask to be relinquished. Instead, the 12 Steps

favor the feminine “power with”

and the “power to be able,”

which fosters a sense of empowerment (Miller 1982). Recovery

encourages surrender and giving

up the need for and the illusion of

control. “The process of recovery

from addiction is a process of

recovering a different, more feminine, sense of power and will”

(Berenson 1991, p. 74). Covington

(1994) has found that women are

able to interpret the Steps in

ways that are distinctly personal,

meaningful, and useful to themselves.

The 12-Step, mutual help

model is a holistic approach that

provides the major factors

women need for recovery. Most

important, the model fosters personal growth within the context

of connections and relationships.

Herman (1992) points out that 12-

Step programs can create the safe

environment for women that is

essential for recovery from trauma. As Covington (1994, p. 192)

states: 

Working with the 12 Steps

from a woman’s perspective

empowers us and helps us

change our lives. Creating a

strong inner place and

believing there is something

in the universe supporting

us helps us to know we are

Chapter 5—Program Design

82
not alone. Then we may be

surprised to find that the

power and healing revealed

in the Steps allows an ease in

living, an acceptance and

serenity, that can transform

the way we experience self,

relationship, sexuality, and

spirituality—which are at

the heart of life. 

* * * * * *

One excellent resource explaining how the 12-Step model operates is “Sororities of Helping and

Healing: Women and Mutual

Support Groups” (Covington

1991b). For programs wishing to

adapt the 12-Step model, materials developed by the National

Institute on Alcohol Abuse and

Alcoholism (NIAAA) can serve as

a resource; one such product is

the NIAAA Project MATCH manual on 12-Step facilitation therapy (Nowinski et al. 1995).

* * * * * * 

Therapeutic Community

(TC) Model

TC models, developed originally

for men as a mutual-help model

for heroin addiction, focus heavily on developing responsibility

and conformity in criminogenic,

antisocial men who have severe

drug dependency. Many practitioners believe it is the most

appropriate form of drug abuse

treatment in correctional settings

(Hooper et al. 1993).

TCs have been in existence for

decades, and their successes have

been well documented (De Leon

1990, pp. 115-1 38). Correctional

system TCs grew out of convincing evidence of success from

such programs as Stay ‘N Out,

established in the New York State

correctional system in 1974. Stay

‘N Out follow-up studies showed

that treatment in a prison-based

TC could significantly reduce

recidivism rates for both men

and women offenders with histories of severe drug dependence

(Wexler and Williams 1986;

Wexler et al. 1990). Women who

stayed in the program for 9 to 12

months did even better than the

men, with 92 percent completing

their parole successfully.

The underlying treatment

principle in TCs is that drug

abuse is a disorder of the whole

person—that the problem is the

person and not the drug; that

addiction is a symptom and not

the essence of the disorder. The

primary goal is to change the

negative patterns of behavior,

thinking, and feeling that predispose to drug use (Hooper et al.

1993).

The original TCs for men used

an authoritarian and aggressive

confrontational approach and

peer pressure to encourage the

development of prosocial behaviors and commitment to a drugfree lifestyle. Staff within the

early TCs were often ex-offenders and graduates of the program. Today, TCs usually combine staff who have a variety of

backgrounds. Some staff will be

certified AOD counselors who

may have been through a TC

themselves and may be in recovery; other staff will be counselors

with a social work or psychology

background and special training

in AOD treatment. This type of

staff mix tends to expand the

scope and capacities of a program. 

TCs have a highly structured

treatment approach, in which

strict community norms govern

appropriate participant behavior,

with an elaborate system of

rewards and punishments

regarding community behavior.

Participants learn responsibility

through a system of graduated

responsibilities and roles. TCs

provide intense residential treatment, with participants living in

a unit isolated from the general

population. This fosters a strong

sense of community and reduces

the negative peer pressure from

other inmates.

The TC model can offer an

ideal environment of support

and help to incarcerated, substance abusing women, with a

depth of nurturance and support

never before known by these

women. The women in these TCs

learn to trust and bond with others, to find hope and opportunity

for change. Many clients have

Chapter 5—Program Design

83

The underlying treatment principle in TCs

is that drug abuse is a disorder of the whole

person—that the problem is the person and

not the drug; that addiction is a symptom and

not the essence of the disorder.
never experienced a structured

environment or someone who

cares. The CSAT women’s TCs

are designed to provide such an

environment. As one program

director put it, “We want the

women to feel like part of a supportive family.” 

The major change from a malemodel TC to a program for

women is the de-escalation in the

intensity and level of confrontation. Men’s programs often have

an intense, in-your-face confrontational style that can be loud

and aggressive, and these apply

overt, coercive pressure to change

an individual’s unsatisfactory

behavior. 

In successful women’s programs, confrontation is used as a

technique but in a context that

also stresses the power of the

woman to make her own decisions. The women’s programs

confront but do so in a supportive way for the woman. At WCI

Village, a peer is always designated to be a woman’s support

when she must face a group. This

rotating support person gives

active reinforcement—either verbally or by touching, according to

what is most reassuring for the

particular woman. Another

example: women are socialized

to please others. This often

means that a woman feels she

cannot speak bluntly about

unpleasant realities or her own

feelings. Being confronted to

speak the truth can be a freeing

experience—a form of empowerment for women.

Setting up a TC requires some

staff who have personal experience with this modality. For those

who have not experienced a TC,

it can be hard to gain a sense of

how the TC milieu operates.

Some articles that can provide

insight about this modality

include works by Hooper et al.

(1993), De Leon and Ziegenfuss

(1986), Yablonsky (1989), Inciardi

(1996), and Pan et al. (1993).

Nielsen and Scarpitti (1995) offer

a look at how language reflects

and defines the subculture of a

work release TC, becoming a

change factor in the thought

processes of the men and women

clients.

An interesting recent article

describes the challenges and

principles involved in moving

from a traditional TC model to a

TC model that serves women

and children (Brown et al. 1996).

The article describes adaptions

made in three categories: structural design issues, treatment

issues, and staff and training

issues.

Male counselors who come out

of male-oriented TC experiences

may have difficulty in adapting

to a women’s TC model. This

problem is discussed in chapter 7

under Selection and Training of

Substance Abuse Treatment Staff. 

Examples of Modification

by CSAT Programs

Six of the nine women’s prison

and jail programs described in

this Guide are TC models. These

programs demonstrate the different types of TCs, depending on

the length of client participation.

These types include the traditional TC (usually 9 to 15 months

in duration), the modified TC (6

to 9 months), and the short-term

TC (2 to 6 months) (see table 3).

In adapting their TC models

for women, the CSAT demonstration programs have made

numerous adjustments. Selected

examples include the following:

• TC program structure. The

OPTIONS TC program in

Philadelphia does not use a traditional hierarchical structure.

Instead, this TC employs a

communal, noncompetitive

approach. Rather than a graduated process for individual

leaders, this program uses program committees as a mechanism for exercising leadership,

cooperation, and responsibility.

• TC components designed to

answer women’s needs. WCI

Village focuses on family

issues, provides a supportive

and nurturing environment for

working on relationship issues,

and sets up a structure that

gives women empowerment

through their job functions

and earns them rewards for

appropriate behavior.

Chapter 5—Program Design

84
Part III

Stages of

Treatment Planning:

The Action Steps

F

or a woman offender with

severe substance abuse

problems, the most promising continuum of treatment and accountability

will include four critical stages as

she moves from initial screening

through custody into the postrelease period. See table 6 for a list

of clinical issues that need to be

addressed, and table 10 for steps

in the continuum of treatment.

The following sections describe

promising practices at each of

these stages: (1) screening and

assessment, (2) in-custody treatment, (3) transition/pre-release

planning, and (4) post-release

treatment and continuing care.

This chapter reflects the practical

knowledge and experience

gained by the CSAT grantees as

they planned and carried out

their treatment activities.

Stage 1: Screening

and Assessment

Screening and assessment represent the first stage in the continuum of care for substance abusing

offenders. This initial stage is critical in providing the framework

and the “road map” for treating

each individual woman. For

treatment programs within correctional settings, the screening

and assessment process serves

these purposes:

• To identify, select, and engage

women who would benefit

from the in-custody treatment

program

• To provide an objective basis

for assessing the severity of the

woman’s substance abuse

problems and working with

the woman to develop an individualized treatment plan

• To provide a framework for

reassessing the woman’s treatment readiness, progress, and

her next-step goals over the

course of the treatment program

• To define the most appropriate

level and type of treatment

87

Chapter 6—Stages in the Treatment/

Accountability Continuum of Care

Table 10. Continuum of treatment

In terms of coordination between treatment and corrections, the most

effective continuum of treatment currently identified includes the following steps:

• Identify the offender as a substance abuser as soon as possible after

entry into the criminal justice system.

• Screen for diversion into treatment as an alternative to custody (as is

done by the Treatment Alternatives for Safer Communities [TASC]

model) or in-custody treatment for those not eligible for diversion.

• Prior to the offender’s release, link (through case management)

reentry treatment planning services with appropriate community

treatment providers; ensure the availability of community treatment

to avoid gaps in care.

• Provide early release to the community conditioned upon a commitment to fulfill a treatment plan negotiated voluntarily by the offender

and counselor with concurrence of the releasing authority (probation,

county parole, the court).

• Provide monitoring of the treatment plan by probation or county

parole in close cooperation with the case manager and community

treatment provider.

• Make a series of clear and rapidly implemented intermediate sanctions available to the supervising authority as alternatives to returning

the offender to custody if she violates probation/parole conditions.

—Adapted from Bureau of Justice Assistance, Design and Implementation

Issues for Drug Treatment in the Jail Setting. Washington, DC: U.S. Department

of Justice, 1991.
and other services that the

woman will need when she is

released back into the community. 

In the past few years, this topic

has become a high-priority issue

for both the corrections and treatment fields. It is being recognized

that treating addicted offenders

saves society enormous sums in

reduced crime and other social

benefits ... and that the most costeffective way to provide that

treatment is through appropriate

matching. Women need to be

matched to the level and type of

treatment most likely to benefit

them—based on the severity of

their substance abuse problem,

their criminal record, their prior

treatment, their family support,

personal resources, and other

factors. To provide low-level

services to a woman who needs

residential treatment wastes

money and resources, besides

discouraging the woman. To provide residential care to a woman

who can benefit from less intensive outpatient treatment also

wastes resources. Since the early

1990s, the field has become

increasingly concerned, and

knowledgeable, about using

screening instruments to help

guide these clinical judgments.

* * * * * *

This section highlights screening

and assessment issues pertinent

to women, based on the experiences of the CSAT-supported

programs described in this Guide.

For an in-depth discussion of

screening and assessment issues,

as well as descriptions and lists of

widely used screening instruments, see TIP 7, Screening and

Assessment for Alcohol and Other

Drug Abuse Among Adults in the

Criminal Justice System (CSAT

1994a). 

* * * * * *

Pre-Screening for

Treatment

Pretrial Screening and CourtOrdered Treatment

In some jurisdictions, screening

may be done by the criminal justice system at the pretrial or sentencing stage. In Arkansas, for

example, judges may transfer

first-time, nonviolent offenders

with substance abuse problems to

the Department of Community

Punishment (DCP). Sentenced

offenders go to the Department of

Community Punishment Facility

in lieu of prison. These women

are court-ordered to have 90 days

of substance abuse treatment.

Women who enter the CHOICES

program come through this

mechanism. For this type of

screening and decision-making

process, the CHOICES staff recommends the following:

• The court may order treatment, but should not specify

the type of treatment program.

That decision should be made

through a thorough screening

assessment by persons trained

to do this screening—often the

treatment providers. In Arkansas, the sentenced women may

volunteer for the Choices program. Based on the assessment

and the availability of program

space, treatment staff selects

women appropriate for their

program.

• Judges and court administrators need training on substance

abuse and treatment in order

to make informed sentencing

decisions involving treatment.

Choices staff spent about 1

year in carrying out such training in Arkansas.

Role of the Classification System

Classification is the process by

which a jail, prison, probation,

parole, or other part of the criminal justice system assesses both

the security risk represented by

an individual offender and, ideally, the individual’s need for

health, mental health, or other

special services. In both jail and

prison programs, this initial classification is often used as a prescreening for the substance abuse

treatment program. Both the

booking screen and the medical

screen give an opportunity to ask

about alcohol and other drug

(AOD) issues.

Since the classification system

is so often used for treatment

pre-screening, it is important to

know how adequately these systems deal with women. Classification systems were initially set

up for male offenders and take a

male perspective. Consequently,

most prison and jail systems have

totally inadequate classification

systems for women; there is a

lack of classification models for

women. The Federal prison system, for example, does not have a

separate classification system for

women. 

* * * * * *

For a thorough discussion concerning the problems of current

classification systems for women,

see “Institutional Classification of

Females: Problems and Some

Proposals for Reform,” a chapter

in the recent book Female

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

88
Offenders: Critical Perspectives and

Effective Interventions (Brennan

1998). This chapter aims to help

managers of correctional agencies, classification directors, treatment providers, and researchers

in designing or considering new

approaches to classifying female

detainees. Brennan concludes

that most of the current genderneutral systems are not well

aligned with either a policy goal

of risk assessment for female

detainees, or with the policy

goals of needs assessment, treatment, and rehabilitation. The

book as a whole (Zaplin 1998)

offers a broad-based perspective

on female offenders, including

theoretical models, treatment

considerations and strategies,

and program approaches.

Among the topics covered by a

number of experts are the relational theory of women’s psychological development, treatment

in a systems perspective, mental

health issues and treatment,

childhood maltreatment and surviving violence, and programs

that work in helping mothers

and prostitutes.

* * * * * * 

Classification issues may be

very different for women, since a

lower percentage require close

custody and supervision. In comparison to men, women inmates

are less of a threat to each other,

staff, or property. According to

Lord (1995), “it is almost

unknown to create classification

systems for women ... [so] we

simply use instruments designed

to assess the dangerousness of

men and overbuild or oversecure

for women at significant cost but

little real gain in increased safety.” A survey by the American

Correctional Association (ACA

1990) showed that:

• Only 20 percent of U.S. jails

and 39 percent of State prisons

have a separate reception or

diagnostic center for women.

• Only 26 percent of jails and 51

percent of State prisons have

full-time classification officers

assigned exclusively for female

offenders. 

• Only 26 percent of jails and 22

percent of State prisons recognize the differences between

men and women and have a

classification system especially

designed for female offenders.

The classification instruments

used to pre-screen for any

woman’s treatment program will

probably have been designed for

men. These instruments need to

be reviewed and possibly modified to reflect issues pertinent for

addicted women offenders. In

modifying the pre-screening

instrument, it is important to

keep in mind that the pre-screening process can be significant in

introducing and interesting

women in the program. The prescreen is thus an opportunity to

help the woman look at her drug

problem and also an opportunity

to encourage her to change it.

The pre-screening and staging

into treatment should be a partnership arrangement between the

correctional and treatment staffs.

This is an area in which some of

the CSAT grantees have encountered resistance. Correctional

staffs may want to control the

decisions about who enters treatment or, in many cases, the institution’s classification system is

simply set up to make these decisions and any change is resisted.

A variety of screening scenarios is

possible, but the important principle is to assure that treatment staff

are comfortable with which

women are admitted for treatment.

* * * * * * 

Chapter 7, “Critical Issues in

Implementing Programs,” offers

some suggestions for forging

mutual arrangements between

corrections and treatment staffs.

* * * * * *

Instruments for

Screening

A nationwide survey of community and corrections programs

that treat women offenders

found these programs seldom use

standardized screening instruments. Instead, the programs

tend to assess need on the basis of

a client intake interview supplemented by observation and by

information from client records

(Prendergast et al. 1995, p. 245).

The researchers concluded that

the failure of many programs to

use a standardized assessment

protocol—that is, a published,

validated instrument—suggests

there is likely to be considerable

variation in the kind and quality

of information obtained on

clients for various areas of need.

The researchers also concluded

that these programs may have an

insufficient information base on

which to develop needed services

and to match clients to appropriate services.

Standardized screening and

assessment instruments designed

and validated for women are not

available. What is recommended

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

89
for women’s treatment programs

is the following:

• Use standardized instruments

that, if possible, have been

normed for the offender population. The validated instrument can form the backbone of

the assessment process. These

standardized instruments offer

certain advantages: training

tools, supplementary resources,

and a common database.

• Add specific questions that

relate to women, such as questions pertaining to physical and

sexual abuse and mental health.

• Choose instruments that match

up with program goals. The

program context will affect the

choice of instrument. Using a

validated instrument as a base,

many programs like to develop

their own individualized

forms. WCI Village, for example, has developed its own

screening form. The SISTER

project uses forms developed

by Walden House, Inc. SISTER

graduates are transferred to

Walden House facilities after

their release from jail. 

Many instruments are available that perform similar functions. Some of the substance

abuse screening instruments

used by the programs described

in this Guide include: 

• Simple Screening Instrument

for Alcohol and Other Drug

Abuse (SSI): A 16-item public

domain instrument adapted

from 13 validated instruments;

administered with pencil and

paper.

• Substance Abuse Subtle

Screening Inventory (SASSI),

developed by SASSI Institute:

An 88-item self-administered

screening tool (used by North

Rehabilitation Facility, Seattle).

• Offender Profile Index (OPI): A

public domain screening

instrument that requires a 30-

minute face-to-face interview

and is appropriate for determining the type of treatment

to be used by the correctional

system. Interviewers must be

trained to use the OPI.

Screening for Admission

to Programs

Men and women respond very

differently to the screening

process. Several of the CSAT-supported projects operate parallel

programs for women and men.

Staffs point out that men respond

to screening in a concrete, factual

way, answering questions with a

word or two. Women have a

more individualized response;

women want to talk about their

answers. Screening for women

can therefore be a therapeutic

experience and a first opportunity for bonding with staff. 

The CSAT programs recommend

that more time be allocated for

screening women into substance

abuse treatment programs than is

provided for men.

Screening for Admission to

Jail/Detention Center Programs

For jail programs, where time is

often limited, it makes sense to

use the classification process as a

pre-screen gatekeeper to the program. This gets women into the

program as quickly as possible.

The principle is to have classification staff make the first cut and to

send a selected list of names to

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

90

Screening Recommendations

1

The screening of women for institutional drug treatment programs

needs to reflect a mutual, collaborative effort between the correctional classification staff and the treatment program staff.

2

It is desirable to have the substance abuse screening done as part of

an institution’s medical screen, where the screening can be done by

a nurse or by some person with a background in public health. This

screening needs to be done by a person who has had experience and/or

training in substance abuse. Some nurses have such training.

The CSAT expert panel on women’s correctional treatment also recommends:

• Review and carefully evaluate the process that correctional counselors

will use in pre-screening for the treatment program. The pre-screen

should not cull out women who are appropriate for the program.

• Provide orientation to the program and training for the correctional

counselors who will do the pre-screen.

• If possible, have a treatment staff person involved on the classification

board to reflect the treatment program’s perspectives and interests.

• Stay in touch with the correctional counselors’ priorities concerning

treatment. Changes in sentencing or security priorities can affect

how much effort these counselors make to interest and sign up

women for treatment.
the treatment staff. It is helpful if

the pre-screen can flag women

who may have program difficulties because of medical, mental

health, or management problems

(for example, women who are

going through detoxification).

Examples of how this process

works for the CSAT-supported

programs include:

• Baltimore 2-week Acupuncture

and Awareness jail-based treatment readiness program.

Classification staff at the

Baltimore City Detention

Center send the program a

selected list of women identified with AOD problems. The

program director then chooses

women to assess for possible

admission, based on security

and trial date status, the nature

of the offense, and slot availability. This program serves

women awaiting trial, primarily for drug-related offenses,

who have less extensive histories of drug use and crime and

are likely therefore to be

released back to the community at the time of trial. 

Pre-screening is based on the

woman’s self-reported alcohol

and other drug use history

and/or on information about

her criminal history.

• Stepping Out TC program, San

Diego. Jail counselors, trained

by Stepping Out staff, do the

pre-screening. Counselors look

at (1) the number of days left

(sentenced inmates must have

at least 50 days remaining to

serve), and (2) the severity of

the substance abuse problem.

If eligible, the counselors

explain the treatment program

to the woman and, if she is

interested, place her name on a

list of prospective participants.

From this list, the Stepping Out

treatment staff screen women

into the program.

For screening into the program, treatment staff use two

scales of the Adult Substance

Use Survey (ASUS), which

takes 7 to 10 minutes to complete. This survey measures

substance abuse severity by

two scales: involvement with

drugs and disruption to the

woman’s life related to substance use. The two scales

should be “in sync” with each

other. Inmates on psychotropic

medications are admitted on a

case-by-case basis. Criteria for

admission into the program

include the following:

– Minimum 50 days remaining to serve

– Custody level appropriate

for programming (general

population)

– No holds (i.e., Immigration

and Naturalization Service,

parole) 

– Sentenced, no cases pending

– Apparent substance abuse

problem, based on the scale

scores

– Willing to participate in program

Screening for Admission

to Prison Programs

Screening for prison programs

does not have to be elaborate.

The concept of matching the

client to a particular type of treatment does not usually pertain in

this context because, in many

cases, there will be only one program available for women in the

criminal justice setting. The

screening is more an issue of

determining whether a given

woman is appropriate for the

available program rather than of

matching (which implies that

multiple treatment options are

available). While matching

inmates to the appropriate

intervention is important, field

experience suggests that prison

programs do not need to use

elaborate diagnostic and matching procedures (CSAT 1993a).

This is because:

• Inmate populations tend to be

quite homogeneous in their

drug use histories and need

patterns. As an example,

assessment shows that fully 70

percent of women in Delaware

prisons need either short-term

or long-term residential treatment (Peyton 1994, p.12).

• Often, treatment alternatives

are limited in the particular

prison or in the entire correctional system.

• External factors such as the

expected time of release are

often more important than a

detailed treatment needs

assessment in determining

whether a woman is eligible

for the program. 

As with the jail programs, prescreening is usually done by the

classifications staff. A medical

examination may also be done

when the woman enters prison.

At Forever Free, a Corrections

Counselor III provides project

oversight and is responsible for

the screening and selection of

program participants. At the

other CSAT-supported programs

described in this Guide, treatment

staff conduct the screening and

selection of participants. The

screening process is usually simple. For example, the Recovery In

Focus program, a 6-month TC in

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

91
Oregon, uses a brief screening

tool that addresses the following

eligibility criteria:

• Adult woman aged 18 years or

older with children aged newborn to 18 years

• Alcohol/drug use causing

problems in two or more life

areas: social, mental, emotional, legal, educational, vocational, marital/family, spiritual,

physical, or with avocational

activities

• Remaining sentence time of 4-6

months before release

• Willingness to participate in

the program; overtly hostile,

disruptive, or combative inmates are not eligible

• No record of being a sex

offender (because children are

involved in the program)

• Ability to participate in treatment sessions (i.e., not actively

psychotic or severely cognitively impaired)

Criteria for Selecting

Program Participants 

In addition to the admission criteria listed above, program staffs

mentioned other important factors they look for. These include:

• Interest from the woman. Does

the woman agree to participate

in the program? An “I won’t

go” response weeds a woman

out of most of these programs,

which are voluntary.

• History of violent behavior.

Programs tend to screen out

women with a history of violent behavior. The director of

WCI Village, however, has

reassessed this and now

admits women on a case-bycase basis who are classified as

committing a “violent crime.”

Some of these women committed assaults during robberies to

get money for drugs, and such

women may be appropriate for

the program.

• Ability to participate in a

mixed cultural group. Within

the program, previous gang

membership may affect the

selection of individuals for certain groups. The West Coast

programs in particular are confronting a situation of women

participants who come from

hostile ethnic gangs. A treatment staff person has to be

aware of this factor during

screening and identify candidates who cannot be added to

certain groups because of the

gang affiliations of other group

members. Senior residents in

TC programs can be very helpful in identifying gang members and possible conflicts. TC

communities also need to work

to disengage participants from

this gang mentality.

Staffs recommend that the initial screening not probe into such

sensitive issues as physical and

sexual abuse. This issue is discussed further in the next section,

Stage 2: In-Custody Treatment.

The CSAT-supported prison and

jail programs suggest that staff

have access to the correctional and

mental health records of potential

participants. These records

should be reviewed prior to

selection of participants.

Including Women With

Co-Occurring Disorders

in Drug Treatment

Programs

Almost no correctional treatment

programs are available to help

women who have the co-occurring disorders of major mental illness combined with substance

abuse. As was discussed earlier,

research shows that an increasing number of women with serious mental illness, who are often

homeless, are being institutionalized in prisons and jails. Such

women may use alcohol and

drugs to self-medicate their mental illness, and these women

badly need treatment for both

substance abuse and their mental

illness. 

Both historical and structural

factors help explain why so few

treatment programs are available

for offenders with co-occurring

mental and substance abuse disorders. Historically, substance

abuse programs have been reluctant to admit those who have a

dual diagnosis. Substance abuse

counselors are likely to have no

experience in working with such

patients and so feel insecure

about treating them. Institutional

barriers are also significant.

Within correctional institutions,

the substance abuse and psychiatry departments are usually

separate entities and are not

administratively housed together. This institutional separation

tends to segregate clients into

separate tracks. When the psychiatry department “owns” a

given inmate, then that inmate is

likely to be diagnosed as mentally ill and the substance abuse

problem may not be considered.

The CSAT-supported women’s

programs described in this Guide

understood this dearth in available treatment for women with

co-occurring disorders, and have

been willing to take on stabilized

psychiatric patients in their programs. However, several proChapter 6—Stages in the Treatment/Accountability Continuum of Care

92
grams have run into institutional

barriers with the mental health

divisions in their institutions. The

mental health professionals have

not been willing to refer their

clients to the substance abuse

treatment program. Against this

kind of background, substance

abuse programs need to be prepared to develop strong working

relationships with the mental

health departments and psychiatrists in their institutions, so individuals from both disciplines

work together as a team. This

issue is discussed further in chapter 7, “Critical Issues in

Implementing Programs.”

The CSAT-supported women

offender programs have found

that many of these women with a

dual diagnosis can handle a substance abuse program, even an

intense TC experience, successfully. Several programs initially

followed the traditional approach

and screened out women with

major mental illness. But, by

admitting these women on a

case-by-case basis, these programs have been able to identify

which women will be able to benefit from their programs. Key factors affecting whether a program

should admit a particular woman

with co-occurring disorders

include the length of the program, severity of symptoms from

the mental disorder, and intensity of the program. The stigma

surrounding mental illness is a

factor that needs to be addressed

by staff members who will be

working in these special programs with women who have

co-occurring disorders.

Length of the Program

Short-term programs can be

more inclusive of women with

co-occurring disorders than

longer programs. A woman will

be less disruptive to the group

during shorter time periods.

Longer term treatment program

staffs may have to pay more

attention to the effects one individual can have on group

dynamics and to make decisions

based on the greater good of the

group over a single individual’s

needs.

The director of the 2-week

Baltimore detention center program says that as many as onethird of their women participants

have an additional psychiatric

diagnosis. These women are stabilized on psychotropic medications as needed and, as long as

the women are not disruptive

and get some benefit, they stay in

the program. The two CSAT-supported jail programs that average

2 months in length (the Stepping

Out TC jail program and the SISTER jail TC program) also admit

women with co-occurring disorders on a case-by-case basis. The

Stepping Out staff believes that

about 15 to 20 percent of their

participants have co-occurring

disorders. These programs will

accept a woman if she volunteers

to participate, is on medication

for major mental disorders,

including depression, and is able

to do the program and function.

If a woman in the program needs

a full psychiatric evaluation, she

can be sent for a 3-day, in-jail

evaluation with a psychiatrist.

Longer programs, especially

TCs, have to be more cautious

about admitting women with cooccurring disorders. In programs

involving milieu therapy, a single

disruptive individual can undermine the environment for the

whole group. Experience at the

Recovery In Focus prison TC is

that many of the women have

personality disorders.

Severity of the

Woman’s Symptoms

What counts is whether the

woman is able to participate

meaningfully in the program and

receive some benefit from participating. It is also important that

the woman not prove disruptive

to others.

Women with a range of psychiatric disorders can participate

successfully, as long as their acute

symptoms are under control. The

Recovery In Focus TC, for example, admits women with such cooccurring disorders as bipolar

disorder, post-traumatic stress

disorder, fetal alcohol effects, and

fetal alcohol syndrome. Staff

members have a background in

mental health. They understand

women with dual disorders and

expect that they may have a more

difficult time than others in abiding by the rules of the program.

Women with co-occurring disorders are also likely to take a little

longer to complete the program

than others. Staff hold many consultations with a psychiatric

nurse. If a woman is unable to

manage in the program, she can

be referred to the prison’s Mental

and Emotional Disturbance

(MED) program.

Intensity of the Program

For TC programs, the women

need to be able to handle the

intensity of the program without

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

93
being overstimulated. TCs rely on

confrontational methods, which

may not work well with women

who have serious mental illness.

The issue of psychiatric medications is a serious concern with

substance-abusing women.

Those in the AOD treatment

community are acutely aware

that certain medications can reinforce addiction. The issue is that

certain medications are addictive

and are associated with the development of drug dependencies.

Such medications are primarily

the minor tranquilizers (benzodiazepines). Today, these minor

tranquilizers are not commonly

used for psychiatric management, as they were in the past.

This issue should not obscure

the importance of psychotropic

medications for women who have

major mental disorders in addition to their drug abuse.

Prescribed medications, including

antidepressants, are important for

women with major mental disorders and the use of these medications should be encouraged. For

such women, psychotropic medications that address the underlying mental illness may be critical

for supporting the woman’s

recovery from substance abuse.

In practice, there is a delicate

balance between medicating for

real mental illness, while not reinforcing the addiction. Women

with major mental illnesses are

often overmedicated because

they are not receiving treatment

for a core issue—the symptoms

that are secondary to physical

and sexual abuse in their lives.

Once these issues begin to be

addressed, the symptoms often

decrease and the medications can

be decreased. Overmedication

also frequently results when

women are misdiagnosed as having a major psychotic disorder,

when in fact they are suffering

from other disorders that manifest similar symptoms—either

Dissociative Disorders and/or

Post-Traumatic Stress Disorder.

The mental health caregiver

increases dosages to relieve

symptoms, but to no avail

because of the incorrect medication. Overmedication then

becomes an issue.

The CSAT-supported women’s

programs have experienced two

distinct types of problems with

medications. In jail programs,

many of the women come into

detention with major mental illnesses; they require but are not

receiving any prescribed medication. Women with dual disorders

need to be stabilized on medication before beginning substance

abuse treatment.

The prison programs have

found a different challenge. In

prison, women tend to be overmedicated and the medication

can be supporting their substance abuse. The WCI Village

TC, which originally excluded

women on any medication,

found that many women were

being overmedicated in prison.

WCI Village staff are now working with the medical department

to sort out which women really

need medications.

Assessment Process for

Jail and Prison Programs

The CSAT-supported programs

stress how important and therapeutic the assessment process

can be for their women clients.

For some women, especially if it

is their first time in prison or in

treatment, assessment can be a

vulnerable time. It is a time when

women start to bond with staff

members; this is often their first

chance to talk about themselves.

Many women feel that this is the

first time anyone has ever

addressed them seriously, oneon-one, as though their lives

matter. It may also be the first

time anyone has addressed their

problems in a nonjudgmental

way. The programs recommend

using the assessment process as a

tool—the beginning of the therapeutic experience.

Recommendations on the

process include:

• Incorporate the assessment as

a tool for developing each

woman’s treatment plan and

for guiding the treatment

process.

• Involve each woman actively

in discussing the results of the

tests, what the tests mean, and

what the results suggest about

suitable goals for her. Women

are very interested in finding

out what the tests show about

themselves and in talking

about this.

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

94

The CSAT-supported programs stress how important

and therapeutic the assessment process

can be for their women clients.
• Provide training for staff who

will do the assessments; staff

need good, nonjudgmental

interview skills. Staff need to

know how to phrase questions

(for example, “Where do you

live” is likely to elicit a richer

response than “What’s your

address?”). Staff also need to

be informed about confidentiality issues. Women offenders

have a right to privacy and the

confidential handling of any

information they provide. 

• Help staff understand the

effect that culture and ethnicity can have on all the significant issues in a woman’s life.

Staff involved in screening,

assessment, and treatment

planning need to be sensitive

about how their own culture,

ethnicity, and life experiences

affect their perceptions and

attitudes. 

• Inform and train staff about the

limitations on the exchange of

confidential information. Those

limitations are not negotiable.

There is a form, “Limitations of

Confidentiality,” used in TASC

programs, which notifies the

offender about the information

that will accompany her

through the system. Also, it is

important for clients to be

informed that any information

representing a threat to institutional security will be communicated to prison officials.

Information protected by the

Federal confidentiality laws and

regulations may always be disclosed to the correctional institution after the offender has

signed a proper consent form.

* * * * * *

For a discussion of Federal regulations, consent, the offenders’

right to revoke consent, and sample forms, refer to CSAT’s TIP

No. 17, Planning for Alcohol and

Other Drug Abuse Treatment for

Adults in the Criminal Justice

System (CSAT 1995a, pp. 73–89).

* * * * * *

• Develop efficient forms and

systematic procedures, so that

each woman’s complete assessment record, summary, individualized treatment plans,

relapse prevention plan and

prognosis, and aftercare plan

can be passed on to those who

will be supervising the client

during the post-release period,

including treatment providers,

caseworkers, and probation/

parole officers.

• Plan to devote adequate

resources to assessment.

Although the screening

process may be simple, the

assessment process is more in

depth and provides the core

framework for treatment. The

assessment may not begin until

after the woman has been admitted to the program and may take

up to 30 days to complete.

The CSAT-supported women’s

programs use a battery of assessment instruments and interviews. These assessment instruments and interviews form the

base for developing, and then

monitoring, each woman’s individualized treatment plan. This

plan will be revised and updated

as the woman progresses

throughout the course of treatment. Especially in short-term

programs, one of the most critical functions of assessment has

to do with planning for continuing care. The assessment process

helps guide the decisions about

what type of treatment and services will be most appropriate for

a woman after her release.

Table 11 lists the areas that

should be investigated in the

assessment process, as well as

special areas of assessment for

women offenders. These lists are

adapted from CSAT’s TIP 7 on

screening and assessment (CSAT

1994a). 

Assessment Instruments

The following instruments were

utilized as part of an assessment

battery by the CSAT-supported

women’s programs described in

this Guide:

• Substance abuse severity, psychopathic personality disorder,

and recommended levels of

treatment: Adult Substance Use

Survey (ASUS) combined with

Level of Service InventoryRevised (LSI-R). The Stepping

Out staff received training in

these instruments, using a

process developed through the

Colorado Department of

Corrections.

• Substance abuse severity; psychosocial history, assessment,

and treatment planning: (1)

Addiction Severity Index (ASI),

which now includes more

questions relevant to women,

as well as sections on living

arrangements and relationships. A shorter instrument is

specifically designed for follow-up. The ASI has been

normed for criminal justice

offenders but not for women.

(2) The Multidimensional

Addictions and Personality

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

95
Profile (MAPP), by John Craig,

is an assessment tool for addictions and a screening tool for

life skills and psychological

issues. 

• Psychiatric screening (co-occurring disorders): (1) Symptom

Checklist (SCL-90-R), (2)

Minnesota Multiphasic Personality Inventory (MMPI) abbreviated form, (3) Brief Symptom

Inventory, (4) Beck Depression

Inventory or (5) assessment by

mental health clinician.

• Motivation and treatment

readiness: (1) Stages of Change

Readiness and Eagerness Scale

(SOCRATES) (40 items) or (2)

the Circumstances, Motivation,

Readiness, and Suitability

(CMRS) scale (42 items); a brief

14-item version of the CMRS is

available. The SOCRATES

instrument corresponds to the

five conceptual stages of

change in the Prochaska and

DiClemente model (Prochaska

and DiClemente 1986).

• Patient placement in community continuing care: (1) American

Society of Addiction Medicine

(ASAM) Patient Placement

Criteria. Several States have

adapted these criteria for publicly funded AOD clients. In

Focus uses the Oregon patient

placement criteria.

(2) Level of Care Index

(LOCI), developed by CATOR/

New Standards, Inc., a checklist compatible with the ASAM

criteria.

• Post-release social services:

Individually developed program forms.

* * * * * *

See the Resource List,

Screening and Assessment

Instruments, for ordering information on many of these instruments. 

* * * * * *

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

96

Table 11. Components of assessment

Areas that should be investigated with all substance abusing

offenders

• Archival data on the client, including—but not limited to—prior

arrests and contacts with the criminal justice system, as well as previous assessments and treatment records

• Patterns of AOD use

• Whether the woman is in withdrawal from alcohol and/or other drugs

• Impact of AOD use on major life areas, such as marriage, family,

employment record, and self-concept

• Risk factors for continued AOD abuse, such as family history of AOD

abuse and social problems

• Available health and medical findings, including emergency medical

needs

• Psychological test findings

• Educational and vocational background

• Suicide, health, or other crisis risk appraisal, including HIV risk

behaviors

• Client motivation and readiness for treatment

• Client attitudes and behavior during assessment

Additional components in assessing women offenders

• Child care; status of the woman’s children

• History of physical and sexual abuse

• Underemployment, limited income, and poor and hazardous working

patterns (such as prostitution or selling drugs)

• Factors limiting opportunities for education and intellectual growth

• Poor health care, inadequate birth control, lack of prenatal care, and

lack of other medical services

• Responsibility and availability of support for care of children, aging

parents, and other dependents

• Guilt associated with a woman’s self-concept as a “bad mother”

• Specific issues for older women: alcoholism, isolation, and fear of

violence

• Special issues for lesbian women: feelings of oppression, effects of

discrimination

—Adapted from Center for Substance Abuse Treatment, Screening and

Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal

Justice System. Treatment Improvement Protocol (TIP) Series, No. 7. DHHS Pub.

No. (SMA) 94-2076. Rockville, MD: Substance Abuse and Mental Health

Services Administration, 1994a, pp. 16, 30.
Promising Assessment

Practices

As the descriptions throughout

this chapter make clear, the

CSAT-supported programs—particularly the jail programs—make

impressive efforts to identify and

provide for the range of their

clients’ needs before release. This

type of approach—a focus on the

multidimensional problems of

women offenders—is typical of

the “most promising” women’s

community programs identified

in a national search (Austin et al.

1992). 

It is important to note that this

“best practice” is not typical of

most women’s programs for

offenders. A nationwide survey

of 234 community and in-custody treatment programs for

women offenders found that

while nearly all assessed the drug

use and drug treatment histories

of women entering the programs, it was less common for

them to assess other areas of possible need, such as health care,

psychological status, vocational

skills, and difficulties in coping

with problems (Prendergast et al.

1995).

Assessment in

Short-Term Programs

In short-term programs, where

the aim is to motivate women

into community treatment, the

assessment is a major program

component. What is needed is to

match the woman to the appropriate level of care in the community. When few treatment

options are available in the community, then it becomes even

more critical to identify other

supportive services, such as

drug-free and safe housing.

Critical areas to assess include

vocational training, child care,

transportation, the woman’s

familial responsibilities, and the

role the woman played in the

criminal offense (was she the primary actor in the crime or was

she acting at the direction of her

significant other?).

North Rehabilitation Facility in

Seattle, a short-term program,

uses a 5-day triage process, with

a four-person triage team that

meets every day, to assess all

admissions. This team includes

three chemical dependency

counselors and an employment

development specialist. The team

looks at chemical dependency

and vocational, educational, and

mental health issues, among others. At intake, the women fill out

a self-assessment form and have

a biopsychosocial interview with

staff. Based on the self-assessment and interview, additional

in-depth assessments are done in

specific identified areas of need.

At the Stepping Out TC project in San Diego, women average 62 days in the program but

have stayed as long as 6 months.

For both treatment planning and

for matching clients to community treatment, this program is

using an assessment system

developed by the Colorado

Department of Corrections. The

staff received training in how to

use the instruments, which

result in recommendations to

these specific levels of treatment: (1) no treatment; (2)

increased urinalyses, drug and

alcohol education; (3) weekly

therapy; (4) intensive outpatient; (5) intensive residential

treatment; (6) TC; or (7) assess

for psychotherapy. This type of

process, using objective means

to assess a person’s progress and

level of treatment need, is very

different from the intuitive

assessment that most counselors

are accustomed to using. It took

the staff more than a year to

come to trust the objective test

results. 

This program points to the

increasing refinements being

made in the treatment-matching

process. The Stepping Out staff

consider their system to be a

“third generation” level assessment, capable of giving accurate

risk and needs assessments along

with recommended treatment

modalities. In the future will be

“fourth generation” methods,

that will allow matching clients,

based on their needs, to a particular treatment provider and

possibly even to the most appropriate therapist.

Assessment in Longer Programs

For longer programs, such as

TCs, assessment is an ongoing

process tied to developing an

individualized treatment plan.

The CSAT-supported programs

suggest the following practices:

• Provide for orientation before

doing in-depth assessment. At

WCI Village, women fill out an

initial assessment form; this

takes 1-2 hours depending on

the woman’s educational level.

Over the next 30 days, the

woman is oriented to the program, learning about TCs and

her job functions. The assessment cycle continues during

the month. At the In Focus program, women start with an orientation by a senior resident

on the program’s rules and

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

97
regulations; a week later, the

woman goes through the

intake process and develops a

treatment plan.

• Continue to assess throughout

the treatment period. Ongoing

assessment is needed, so that

clients move to the appropriate

next stage of their treatment in

a timely manner. Also, as

women move through the program, their levels of trust, their

ability to introspect, and the

way the women perceive past

experiences may all change. It

is important to reassess the

woman’s situation, because

her original responses during

screening can change. The

treatment team also needs to

do a regular assessment of how

the woman is progressing in

terms of her needs and goals.

One program, for example,

does a staff team review of

each woman at each level in

the program (about every 3 to

4 months).

• Start assessing for needed

services well in advance of discharge. Programs bring in

outreach coordinators or case

managers long before the

woman is released to the

community. At In Focus, for

example, this component

begins 90 days before the

woman’s release. Some elements—such as family support

and reunification components,

education, and vocational training—are addressed throughout

the treatment program. 

Each woman’s screening and

assessment record, along with

the treatment plan and prognosis, needs to be summarized and

made available for the continuing care treatment providers,

case managers, and probation

officers who will work with the

offender in the community. The

summary and transfer of a

woman’s records should be done

with the woman’s consent to

release of information. Assessment results also need to be compiled to assist in program evaluation and research.

Stage 2: 

In-Custody

Treatment

Once the screening process is

over, appropriate women should

enter the treatment program as

quickly as possible. According to

the CSAT grantees, keeping the

women on waiting lists is counterproductive and should be

avoided if at all possible. Waiting

lists are particularly unsatisfactory when women are mandated to

treatment by the court and then

must wait to enter the program,

so that treatment actually

extends their period of incarceration.

In planning and operating

their in-custody programs for

women offenders, the CSAT

grantees have encountered a

number of common challenges.

Although the programs differ in

length and type, the problems

they have faced, and the strategies they recommend, reflect a

set of shared common perceptions about who these women

are and how the women can be

helped. All these programs—

whether in detention centers or

State prisons—serve women

offenders who have long-term,

severe alcohol and drug abuse

problems. 

Planning the Program

In initially planning the program

with corrections administrators,

certain issues are critical. These

pertain to:

• Desired physical environment.

Whenever possible, a separate

pod to house the women in

treatment is a tremendous

advantage for every type of

program. Living together is a

kind of base for developing a

supportive, family-type environment among participants

and it insulates the women

from the general population.

In the CSAT-supported programs described in this Guide,

all have been provided with

separate housing for their program participants; the programs also have a separate area

for their program activities. A

few, such as WCI Village, have

a completely separate facility

for their residents so that the

women do not mix with the

general population for meals,

recreation, and other events.

This type of separation is

important for long-term TCs.

To have their own facility,

projects may have to make

some compromises. For example, one CSAT project agreed

to house pregnant addicted

women in their program facility. The women needed this

separate housing and the program has adapted to having

some women who will be able

to remain, even if these

women violate the rules.

(Normally, a woman who violates the rules could be

expelled from a TC.)

• Space needs. Space is a great

problem under current crowded conditions in the correctionChapter 6—Stages in the Treatment/Accountability Continuum of Care

98
al system. Programs need adequate room for meetings and

other activities. The Forever

Free program uses a large trailer set up in the yard for their

activities—this inexpensive

strategy provides room for

four offices plus classrooms. A

second urgent need tends to be

space that offers a friendly and

inviting environment where

child and family visits can take

place. 

• Scheduling issues. In some

States, such as California and

Oregon, vocational rehabilitation is required for prisoners

for up to 8 hours per day.

However, intensive substance

abuse treatment is a full-time

activity. Full-time vocational

schedules conflict with intensive treatment needs. TCs provide a full schedule of events

throughout the day. Some programs have been able to

arrange for treatment hours to

count toward the vocational

requirement, so that adequate

treatment time is available.

Part-time treatment schedules

are less desirable than longer

treatment hours, since the

fewer hours may not be

intense enough for the population of incarcerated women

with severe substance abuse

problems. 

• Sufficient resources. Outside

providers are often brought in

under contract to manage

treatment programs in correctional settings. Planners in correctional settings need to

involve these providers at an

early stage. In some cases

reported in the literature, programs have initially had to

struggle with inadequate

resources because of budgets

that didn’t include basic supplies needed by a treatment

program. These supplies

include paper, pens, videotapes, curriculum materials,

workbooks, photocopying,

and training resources. 

Setting Appropriate Goals

It is important to be realistic

about what a treatment program

can achieve. There are several

dimensions to this realism. First,

substance abuse is a chronic condition, and lapses and relapses

must be expected. Success is

measured in many ways besides

abstinence. Second, addicted

women offenders are difficult

clients who need to make fundamental changes in many areas—

not just in their substance use.

Many must learn to trust and

bond with others; to grow in selfesteem and in their ability to perceive, establish, and defend their

own personal boundaries; to

learn basic coping skills; and to

learn the vocational skills for selfsufficiency. Such fundamental

change is not easy—it takes enormous work and commitment by

the individual, and it takes time.

Time is the essential driver in

limiting what a program can realistically achieve. As a general

guide, the CSAT-supported programs suggest what would be

realistic goals for three types of

programs: (1) intensive shortterm, often pretrial, programs in

detention centers or jails (about 2

weeks), (2) mid-length programs

in jails, community punishment

facilities, or prisons (such as 2-3

month TCs or 4-6 month less

intensive programs), and (3) midto long-term full-time residential

and TC programs in prisons (3-18

months).

(1) Short-term programs, usually held in detention centers or

jails, need to focus on the goal of

motivating women into treatment and on their reentry to the

community. The women need an

upbeat, enthusiastic boost about

how much treatment can help

them. As one project director put

it, “This is the rah-rah type of

approach.” In this short time

frame, women need to feel

accepted, to feel hope, and to be

introduced to the concept that

treatment can help them with

their lives. The program at the

Baltimore Detention Center uses

therapeutic motivation that

focuses on life consequences

from substance abuse. This therapeutic style is based on William

Miller’s motivational interviewing techniques (Miller and

Rollnick 1991). Using an empathic counseling approach, the

counselor gives the woman feedback on the life consequences of

her behavior. Using this theory of

“reflection and mirroring back,”

the counselor connects the consequences of addiction to the

events happening in a woman’s

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

99

It is important to be realistic about what a

treatment program can achieve.
life and helps the woman to see

those connections and consequences. This feedback serves to

provide enlightenment about her

opportunities for change. At the

end of the 2-week program, as

many women as possible will be

connected up with community

treatment programs. The major

elements in such brief programs

will be:

• Stabilization (the woman will

be drug free, detoxified, oriented, and her medical needs will

be determined; methadone

treatment placement in the

community should be considered)

• Needs assessment process (one

project director called this

“screening the woman and

reaching out to engage her in

treatment during this brief

window of opportunity”)

• (Desirable option) Acupuncture

to help provide withdrawal

symptom relief during the

detoxification process

• Therapeutic motivation to

treatment (this intervention

may include education and a

therapeutic component, as

well as relapse prevention concepts and skills)

• Case management directed at

the woman’s immediate treatment needs and ancillary

needed services, such as child

care

• Health screening, especially for

sexually transmitted diseases

(STDs), and risk education

about HIV and other STDs

• Community resources and referrals for the woman’s identified

needs, including safe and

sober housing 

In these short programs,

women are often still in drug

withdrawal when they arrive. It

is a treatment readiness situation.

As the director of the North

Rehabilitation Facility’s program

points out, the more sophisticated the assessment process, the

better. Since staff have so little

time to work with the women, it

is important to understand the

stages of change model and to be

skillful in using and interpreting

screening tools. Staff can then

identify where the woman is in

terms of her motivation to

change, and place her in the most

appropriate community treatment setting.

(2) Mid-length programs (2-3

months), often held in jails and

community punishment facilities,

also need to focus on pretreatment and treatment readiness

issues. Especially in intensive TC

programs, the women can get a

glimpse of what residential treatment will be like, including the

support and bonding that is possible. The CSAT grantees recommend that these programs aim to

bring women along through the

pre-stages of treatment. These

pre-stages include the following:

• Developing problem awareness.

The woman needs to develop

an awareness that she has a

real problem: that substance

abuse is having a significant

adverse impact on her life and

the lives of her family, especially her children.

• Resolving ambivalence. The

woman needs to work through

her ambivalence about giving

up substances, and deal with

grief and loss issues and with

how her relationships fit into

her substance abuse and criminality patterns.

• Identifying barriers to recovery

and action steps. The behavior

of each woman will be individual. Therefore her barriers and

steps will also be individual. It

is when the woman is ready to

take action that treatment can

really begin.

Women offenders cannot

move through these stages of

change until they resolve certain

developmental and emotional

issues. The women must be able

to be introspective. Initially,

women offenders with a history

of addiction do not respect their

own feelings and may not be in

touch with their feelings. As previously mentioned, they often

feel victimized and so powerless

they do not understand the cause

and effect relationship between

their behavior and its consequences. And most importantly,

the women need to feel hope

that it is in their power to change.

The shorter 2-3 month treatment programs need to establish

a rhythm that acknowledges and

reflects the woman’s emotional

state. For at least the first week

after she enters the program, the

woman will be in crisis. She will

again be in crisis for about 2

weeks just before she leaves. It is

critical to get the women comfortable and stabilized, since people in crisis do not learn.

It represents a great step forward if, by the end of these programs, the woman has developed

an internalized motivation for

treatment. This type of motivation

is demonstrated by an evaluation

of Forever Free program graduates who subsequently entered

community residential treatment

(Prendergast et al. 1996). When

asked why they entered treatment, the most common response

given (16 of 20 women) had to do

with being “tired,” “disgusted,”

“wanting to change,” or to “save”

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

100
self. Three women mentioned

getting or keeping a job or parenting issues (being a better parent or getting children back) as

their motivation. External pressures from all sources—from the

criminal justice system, attorneys,

or family members—were mentioned as a factor by only three

women.

Major elements in these 2-3

month full-time residential (or 4-

6 month less intensive programs,

such as Forever Free) may

include the following:

• Stabilization (detoxification if

needed, with medication

needs stabilized)

• Psychoeducation (including

both educational components

and therapeutic interventions

and groups)

• Process groups dealing with

women’s issues

• Individualized relapse prevention skills development and

planning

• Orientation and participation in

12-Step and other support groups

• (Optional) Family reunification

and parenting components

• Work on criminogenic thinking

patterns and behavior modification (in some States, this element will be provided by the

institution instead of the treatment program)

• Individualized treatment planning (since women will need

ongoing treatment and supervision in the community,

matching of the woman to the

appropriate level of postrelease care is very important)

• Medical, dental, and psychiatric screening and treatment

(education/counseling about

high-risk behaviors regarding

STDs and HIV/AIDs is critical)

• Case management to identify

post-release needs and

resources for women who will

not be entering residential

treatment; this will include the

areas of safe and drug-free

housing, connections to local

mutual-help groups, financial

aid, vocational skills, and child

care/custody issues

(3) Mid- and long-term fulltime residential programs (3-18

months). The goal of these intensive residential programs, particularly TCs, is to provide the

woman with her primary treatment base. The TCs, as described

previously, also aim to make

fundamental changes in the

negative patterns of behavior,

thinking, and feeling that predispose to drug use. The TCs

work through all stages, from

pretreatment readiness and

motivation through actual treatment. Drug treatment is combined with a structured increase

in the person’s personal growth

and responsibility. Participation

in a TC represents a major commitment by the woman.

For offenders, the prison TC

provides the base for reducing

recidivism and relapse. However,

it should not stand as end-stage

treatment. Based on a large body

of literature in the fields of both

treatment and corrections, it

appears that the most effective

strategy involves a three-stage

intervention process (Inciardi et

al. 1994). The regime is adapted

to the client’s changing correctional status: incarceration, work

release, and parole or other forms

of community-based corrections.

For example, the women participants at WCI Village move

through the following stages:

from (1) orientation, to (2) primary TC prison treatment at WCI

Village, to (3) a secondary transitional work-release TC in the

community, to (4) a tertiary stage

of living in the community under

the supervision of parole or some

other surveillance program

(TASC), with outpatient counseling and group therapy continued

at the work-release TC.

A prison TC needs to be organized in phases or levels, so that the

woman progresses through the

program at her own pace. The

woman also needs to take responsibility for her own progress. At

WCI Village, the orientation phase

is devoted to helping the woman

commit to treatment. There are

five subsequent levels. Progression through the program’s levels

depends on the amount of time

spent in the TC and on the completion of requirements within

each level. The fifth, highest level

is senior resident, and is earned by

those who have been in the program for at least 18 months.

Progression from one level to the

next is seen as a reward for appropriate behavior, and each level

brings new privileges. To move to

the next level, a woman must give

a presentation to staff describing

why she feels ready for the higher

level; staff then make the determination. From level five, women

progress to the next stage—the

transitional work-release TC in the

community. 

Developing an Individualized

Treatment Plan

For each woman client, the

assessment process needs to be

ongoing. The woman should

meet regularly with her counselor about her plan, helping to

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

101
set her goals and to discuss her

progress. The treatment team

also should have regular meetings with the counselor to assess

how the woman is progressing

toward her goals. The goals

should be very concrete and specific, so they can be measured.

“Increasing self-esteem” is too

vague. Goals should be specific to

the individual and have a target

date. For example, a goal might

be for a woman, within 1 month,

to stop retreating to her room

instead of facing issues in group.

Treatment

Recommendations 

and Strategies

The CSAT-supported women’s

treatment programs have

encountered a number of challenges as they have implemented

their programs. Their recommendations and strategies for dealing

with these issues are described

below.

Issue 1: Uncertain client

schedules and assignments

Programs in detention centers

particularly face complex scheduling problems. Some of these

include periodic disruptions to

the program schedule caused by

lock-downs and other security

needs; patients being relocated

or transferred during a treatment

cycle because of overcrowding;

and the difficulty of scheduling

treatment because of the initial

quarantine and impending trial

dates. In county jails, the population is characterized by rapid

turnover.

The CSAT grantees suggest

both adopting a creative and flexible attitude and, if possible,

designing the treatment program

for flexibility. This is an advantage for handling the uncertainties, but it also promotes a more

individualized approach. Since

the number of women involved

in these programs is generally

small, the more individual and

flexible approach will serve the

women better. Some strategies

used by the women’s programs

include:

• At the OPTIONS TC program

in a county system, the program is designed in 8-week

cycles; some topics are consistent across all cycles, but each

cycle addresses the specific

topics that fit the needs of the

particular women in the group.

In this system, new inmates

can enter at any time in any

cycle.

• Admission to the OPTIONS

program is continual; a

Newcomers group is used to

orient new clients to the program. The Newcomers group

permits staff to assess each

new client’s needs, to assess

potential adjustment problems, and to confer with other

group leaders about appropriate client placement.

The WCI Village prison project

director also points out that flexibility is important, because the

models for treating incarcerated

women are new. This is an underserved population. Experience

and emerging research findings

will suggest what is working well

and what could possibly be modified. If staffs keep an open mind

as they work with the women,

they may come up with many

new ideas for improving the program process.

Issue 2: Attracting clients to

the treatment program

The women’s programs supported by CSAT have had few difficulties in attracting women to

participate. At the Recovery In

Focus prison program, for example, virtually 100 percent of the

inmates volunteer to participate.

At Forever Free, there are more

applicants than program slots.

One exception is a program

where untrue rumors were circulated among the general prison

population. This initial “bad

press” has been overcome by orientation sessions when new

inmates arrive, presentations in

the living units, and by inmates’

observation of the program’s

actual performance. A second

program found their applicant

pool was reduced when the corrections counselors, who were

responsible for recruiting participants at the classification prescreen, began to have different

priorities.

Both Stepping Out, a jail program, and WCI Village, a prison

program, consider it important to

recruit the women into treatment

immediately after their sentencing. Both programs hope to avoid

having new inmates get negative

messages about the program and

other adverse effects from other

inmates in the women’s living

environment. Both these programs have also begun doing

active recruitment within the living units. 

The CSAT grantees report

some of the major reasons

women come to their programs

include:

• The positive way they’re treated: Inmates see that the

women are treated with

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

102
respect and caring in these

programs—something that

many have rarely experienced.

• Curiosity about themselves: In

the Stepping Out program, the

director said the women are

very interested in the intensive

assessment process and in discussing and finding out how

they compare with other

women.

• Meeting court mandates: Some

of the programs help women

meet the court-ordered

requirements for reuniting

with their children or treatment for themselves. Most of

the programs have components aimed at advocating for

and promoting the woman’s

self-interest: legal advocacy,

child visits, counseling about

parenting the children, and

foster care for children.

• The individualized approach:

One director stated that the

“best hook” for bringing

women into treatment is the

individual type treatment her

program offers.

• Fear and shame: Women who

are incarcerated and taken

from their families are often

ashamed and humiliated; they

are facing the consequences of

their substance use and are

eager for help.

• Self improvement: Many

women in correctional settings

want to take part in programs

aimed at self improvement and

personal growth.

Issue 3: Voluntary vs. mandatory participation

Nearly all the women in the programs described in this Guide

enter treatment voluntarily. The

exception is WCI Village, where

about 90 percent of the women

are court-ordered and 10 percent

are voluntary. At the Choices

community punishment facility

in Arkansas, some women are

mandated to treatment by the

courts, and these women may

voluntarily choose the CHOICES

TC program. If treatment is

refused, the court may opt for the

prison alternative. If not mandated to treatment, women may

select the Choices program or a

less intensive drug education

program. 

At the Recovery In Focus program, the first group of women

was mandated to the program

(all women since then have been

voluntary participants). This first

group of mandated women was

very angry about the situation. In

dealing with this angry group,

the project director came up with

a highly successful strategy that

now undergirds the entire program. The women were asked to

help develop the new program

and to be involved in key decisions—to help set the rules, the

sanctions, the procedures that

would be followed. Their anger

melted and they eagerly took on

responsibilities. Ever since, the

women participants have had a

strong voice in running this program, including self-monitoring

(see table 7 in chapter 4). This

program director recommends

that women’s treatment models

use this strategy—allowing the

participants as great a voice as

possible in running the program

and setting and in upholding the

rules and policies.

At WCI Village, where women

enter the program on both a

mandatory and a voluntary basis,

the program director says that this

distinction is basically irrelevant

to the treatment process. The

women who come in on a mandatory basis are angry initially, but

this dissipates in about a week.

Both the mandatory and the voluntary participants are involved

in a similar denial process; the

voluntary group is no more

“ready” for treatment than those

who are court-ordered. The experience at WCI Village is that it

takes all women—whether courtordered or voluntary—about 21⁄2

to 3 months to become emotionally engaged with the program and

committed to it. At this point, the

women begin to identify the critical issues in their lives, to move

past denial and toward being in

touch with their feelings, and to

start really listening to other

women who are past this early

stage. 

Issue 4: Program rules and

sanctions 

Rules are the backbone of any

type of women’s treatment program. They need to be stated in

an absolutely clear manner, and

the consequences of violating the

rules should also be clearly stated. Other recommendations

from the grantees follow: 

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

103

Rules are the backbone of any type

of women’s treatment program.
• Rules need to be specific and,

with this population, they

must be consistently enforced

by everyone—staff, security

officers, and participants.

• Goals for each woman need to

be specific and individualized,

with a time limit. The woman

helps to set her own personal

goals, and she is expected to be

responsible for working

toward and meeting those

goals. Then if the woman does

not meet her personal goals,

she is in essence choosing not

to stay in the program. This

means that failure to progress

in the program–and the decision to leave the program–is a

choice made by the woman

and shown by her actions. In

this framework, women

understand that failure

depends on their actions; it is

not a decision being imposed

externally. 

• Institutional rules should not

override program rules. In

other words, if a woman

“screws up” in the program,

the institution should not

impose extra days of incarceration or add some other sanction to her sentence.

Issue 5: Environment suitable

for women

In developing a program for

women, it’s important to set up

an environment in which women

will be comfortable and thrive.

This kind of environment helps

to explain why the CSAT programs have been so successful at

drawing women in and retaining

them in treatment. Some of the

critical elements that resonate

with women include:

• Taking an individualized

approach. While a very concrete approach works with

men, women want to deal with

issues on an emotional basis.

Women want an approach that

is individualized to themselves.

• Building on women’s natural

behaviors. Men and women

behave in very different ways

while incarcerated. Men “do

their own time.” Women tend

to form their own “families”

and informal networks while

in jail or prison. Programs can

successfully build on this need

of many women to connect in

a supportive way with others.

The TCs actively promote a

sense of the group as “family.”

One of the programs also helps

the women to identify who

within the group they choose

to relate to as parent and child

figures, and to understand

these factors in their relationships. 

• Modifying the confrontation

tone. As discussed earlier, the

authoritarian, harsh confrontation style of traditional male

TCs is not appropriate for

women. Many TCs for men, as

well, have toned down their

stark, “in your face” confrontation style. Research done by

William Miller demonstrates

that confrontation begets confrontation. That is, aggressive,

“finger pointing” behavior by

the staff leads to aggressive or

avoidant behavior by the

clients. Alternatively, empathic

staff responses lead to more

appropriate, participative behavior by clients.

The entire context of confrontation must be adapted for

women. To help gain a sense of

empowerment, women do

need to be assertive and they

need to learn how to confront

another person in an effective,

assertive manner. The language used should never be

degrading. From the standpoint of experiencing power,

the women need to learn how

to address issues with others in

a frank, controlled, caring,

assertive, and yet supportive

way. Women can be very hard

on each other, yet supportive

at the same time.

Some women may need to

have their natural confrontation style toned down. A

California program reports

that some women, especially

young women from ethnic

gangs, use aggressive body

language and operate verbally

on a very loud, hostile plane

just short of violence. These

women must learn that the

way they relate at home and in

their social group does not

work in a treatment setting.

And beyond that, the women

need to learn alternate ways to

behave while in treatment and

at home.

• Providing rewards and honoring achievement. These

women’s programs have

found that honoring the

women clients is very important for both the women participants and the staff. Both

participants and staff need

affirmation. Official ceremonies are affirming for the

women, and they also help to

encourage and bolster staff

morale. Staff feel rewarded for

each woman’s achievement.

Among these programs, the

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

104
general practice is to have an

awards ceremony when a

woman or group completes

each program cycle. There is

also a graduation celebration

when a woman completes the

program. These ceremonies

often include a cake, the

awarding of a certificate, and

official recognition from the

podium by staff and other participants. Several, such as the

OPTIONS program, also have

anniversary celebrations for

their graduates. These are gala

events that renew ties with the

graduates and offer inspiring

role models for the current

program participants.

These events bring the community together as a bonding

experience. Some suggestions

from the CSAT programs: have

a play day for the annual celebration, with picnics, games,

and festivities for fun. The

Recovery In Focus program

has found videotaping to be

very popular with the women.

They videotape the award ceremony and videotape the

women as they’re involved in

the play day games and other

activities. At the end of the day,

the videotape is played for

everyone to enjoy.

At the OPTIONS program, a

project committee is used to

involve all the women clients

in planning some special project, such as a play, a graduation

presentation, or a program

newsletter.

Issue 6: Handling denial

issues 

Working through a woman’s

denial is a central hurdle for

treatment programs. The programs described in this Guide

view denial from two different

perspectives, and therefore deal

with it somewhat differently.

Planners setting up new programs are also likely to use one or

the other of these approaches.

The first approach represents

the traditional 12-Step model, in

which denial is seen as a symptom of the disease, with the person blocking out and refusing to

accept the reality of his or her

substance abuse problem and the

negative effects this has on self

and others. Confronting and

breaking through that denial is

perceived as central to recovery.

For those using this 12-Step

approach, the CSAT grantees

made the following suggestions. 

• Self-esteem issues. The Forever

Free program has tested the

self-esteem ratings of their

women participants as they

enter the program and then

move past the denial stage.

The scores show that selfesteem, already very low in

these women, plummets virtually to zero as they face the

overwhelming reality of their

substance use problem and

their own deficits. The program director emphasizes how

vulnerable the women are at

the stage when they break

through their denial. The recommendation is to provide

every possible means of support to the women during this

period. At the Forever Free

program, breaking through the

denial is the low point in selfesteem and then the women’s

scores begin to rise.

• Support strategies. At WCI

Village, the program is set up

so that women do not feel isolated or alone when they face

through their denial. The program director says that, if a

woman is to break through her

denial, she must have support.

Whether standing to address

the group or sitting in a circle,

the woman has a buddy who is

beside her to offer support,

either verbal or through touching. This support person is

there to say, “you’re OK,”

“we’re here to help you get better.” The particular support

person rotates so that all the

women in the group are taking

part in what is designed to be a

supportive and nurturing

environment.

The second perspective, based

on a therapeutic model, addresses denial in a different context. In

this perspective, women are not

seen as denying their addiction

and its consequences. Instead,

women are seen as ambivalent

about giving up their substance

use because they are deeply

attached to it. The addiction is

functional for these women. For

many, it is numbing their depression and the pain they feel in

their lives and from abusive relationships, present and past. As

one woman client said, “Alcohol

is the only thing in my life I have

control over; when I drink, I

know just how I will feel.” It is a

dynamic similar to that for

domestic violence. It is not helpful to say to a woman who is

being abused, “just leave the

guy.” The woman has too great

an investment in the relationship—or is too dependent on it—

to let the relationship go.

In this perspective, a woman is

denying and ambivalent because

she has a compelling attachment

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

105
to the drug. There will be grief

and loss at giving it up. The way

to help clients is to help them

address the nature of their

attachment to drugs. What is the

woman getting out of it? Why is

the need so compelling? How

does this attachment affect her

individually? With this perspective, the approach is to explore

these issues of attachment, grief,

and loss. Confrontation would be

used only when working with

highly antisocial women. 

Issue 7: Addressing intense

emotional issues

A very high percentage of addicted women offenders have experienced physical, emotional, and

sexual abuse. Some have abused

their children. These are intense

and emotionally charged issues

for the women. If women do not

deal with these issues in their

lives, they are at increased risk of

both relapse and recidivism.

The issue for treatment programs is how best to address

these topics. Several of the programs urge great caution.

Counselors need training in how

to work with women on these

issues. Women often have great

difficulty acknowledging the

abuse that has been done to them

and may be very disturbed when

facing this. However, these issues

are so central to a woman’s

recovery that they must be

acknowledged and addressed.

The CSAT-supported programs suggest two principles.

First, don’t ever brush off this

topic when it comes up. If it can’t

be handled within the program

context at the particular time,

then it should be acknowledged

as a serious issue important for

recovery. The woman should be

given next-step options for how

and when she can be helped with

this. The second principle is

“guided self-disclosure.” Women

are not pushed to bring up this

topic. They are instead given

opportunities to bring it up as an

issue, such as through the counselor’s inviting of comments or

open-ended questions.

Following are suggestions for

handling these emotional issues

at different stages in treatment. 

• During screening and assessment. The screening process

should not ask questions about

traumatic emotional issues

unless the program expects to

help the woman deal with

them. Such inquiries should

not be made if the woman will

be going on for treatment elsewhere. Some program directors

questioned whether taking a

history of physical or sexual

abuse is appropriate during

screening, since such abuse is

so widespread for these

women. Early in the program,

some women don’t even realize they have been abused.

Others lie about it initially. As

one director put it, “This topic

comes out naturally during the

group work; there’s no need to

ask about it during screening.”

Some screening instruments

are set up to elicit researchoriented yes/no counts; this

approach is not desirable.

Instead of simple “yes”/“no”

responses, women should feel

encouraged to discuss their

issues. When emotional issues

are asked about during screening, it is suggested that an invitational tone be used, so the

woman can answer any way

she wants. For example, “Many

of our women have experienced physical or sexual abuse.

Is this an issue you wish to discuss right now?”

• In short-term programs. For

short-term programs, which

do not have the time to work

through these intense emotional topics with a woman, it

is recommended that the topic

not be glossed over for any

woman who brings up the

issue. Rather, the issue should

be briefly processed. It needs to

be pointed out that (1) this is

an important issue affecting

many women who have addiction problems, and (2) it is critical for a woman’s recovery

that she talk about and have

help in dealing with any physical, emotional, or sexual abuse

in her past or current life. This

should be used as an encouragement for the woman to

enter community treatment—

that she will receive help with

this when she goes for more

extended treatment. Referrals

should also be available.

• In mid- and long-term programs. In mid- and long-term

therapeutic communities,

abuse and victimization issues

need to be dealt with in depth.

At WCI Village, the project

director says that it would stigmatize the women to have separate process groups for sexual

and physical abuse or for those

with the human immunodeficiency virus (HIV). Abuse is

such a pervasive problem for

everyone that it is a theme in

the ongoing flow of group discussions—”this is something

that happened in your life, that

happened in the lives of most

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

106
people here.” The effect of feelings, like depression, is another

pervasive theme throughout.

Staff of the Forever Free

Program in California point

out that, in focusing on sexual

issues, it is important not to deemphasize other forms of

abuse, such as physical, emotional, or psychological abuse.

Although 90 percent of the

women in the Forever Free

program have experienced sexual abuse and this becomes the

program norm, there is a subcategory of this abuse that is

even more severe. It involves

primary sexual abuse coupled

with a secondary form, such as

psychological abuse. An example would be a person who

was sexually abused and

locked and restrained in a closet for a long period of time ...

suffering some sensory deprivation as well. This more

severe, multi-level abuse may

raise issues beyond the treatment capabilities of some drug

treatment programs, depending on the counseling/therapy

capabilities of staff. Such problems may require a referral to

psychiatric counseling as well

as work within the drug treatment program.

Most of the CSAT-supported

programs have been able to refer

women to psychiatric services

when they may need additional

help. Having a staff member with

expertise in mental health issues

is an advantage for identifying

and caring for such women.

Issue 8: Retaining women in

treatment 

Research shows three important

facts about treatment outcomes:

(1) successful outcomes are related to how long a person stays in

treatment, (2) women generally

are not retained in treatment at

as high a rate as men, and (3)

retention tends to be a problem

in TC programs. A program’s

ability to retain a high rate of its

woman participants until they

complete the program is therefore critical.

The in-custody programs

described in this Guide are quite

new programs. Although all but

one of these programs are voluntary, none is reporting significant

retention problems. Those

reporting on actual data show

very successful results in being

able to retain the women in the

programs. Examples include:

• Baltimore Detention Center pretrial program: Graduation rates

have been steadily rising.

Currently, 90 percent of the

women graduate from this 2-

week program.

• Forever Free prison program: A

review of 2 years of Forever

Free program data shows that

more than 92 percent of

women admitted to this 4- to 6-

month treatment program

complete it.

The WCI Village program

director has the following comment about retention, “Once we

help the woman get past her first

difficult issue—whatever that is,

whether it’s being abused herself

or abusing her child—then that

woman stays.” However, TC programs such as WCI Village are

intense and require a high level

of personal commitment. Some

women do drop out. WCI Village

now offers drug education classes for women who drop out of

the program so they have some

continued involvement on alcohol/drug issues.

More severe retention problems are likely to occur at the

community level, after women

offenders are released from

prison or jail. This issue is discussed later in this chapter. 

Issue 9: Sustaining motivation until discharge into the

community

When a participant completes an

in-custody treatment program,

the person should not be

returned to the general population of the prison or jail. This is a

lesson learned from women in

the Stay N’ Out program and in

many programs for addicted

male offenders. Experience

shows that treated offenders

need to move on to the next stage

in the rehabilitation process right

away. When they are returned to

the general population and must

wait for release, people lose their

treatment gains.

In all the CSAT-supported

women’s programs, every effort

is made to admit women in conjunction with their anticipated

release dates. However, women

do not move through treatment

at the same pace, so the date

when they will complete treatment can’t be exactly predicted.

There are also many uncertainties and changes in the dates

when inmates are released.

The grantees have developed a

number of strategies for the

many cases in which women

have completed treatment, but

must wait in the institution for

release. (The best option, of

course, is for the sentence to be

tied to completion of treatment,

so the woman can proceed

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

107
directly from completing her incustody treatment program into

community-based treatment and

supervision.) These strategies

include: 

• Separate dormitories. Several

programs have been able to

arrange for separate buildings

or dormitories to house

women who have completed

treatment. This includes the 2-

week Baltimore detention center program, the Choices community punishment facility,

and WCI Village—where program graduates live in an independent living program for

trusted, long-term women

offenders.

• Senior program positions. At

Recovery In Focus and WCI

Village, graduates can stay on

as senior residents and mentors, continuing to be involved

in the treatment program. New

job positions were created for

these women at WCI Village,

which also strengthened and

enhanced the chain of command. These positions include

resident counselor, house monitor, facility manager, coordinator, and senior coordinator.

Seniors run groups and take

part in the program. However,

expanding top positions in TCs

can only go so far. If too many

veterans remain at the top of

the seniority structure, this will

shut down opportunities for

other clients to progress into

positions of increased responsibility. 

• Continued services. In the

Baltimore detention center

program, women still in custody after the 2-week program

participate in a weekly

acupuncture aftercare group

and in twice-weekly psychosocial aftercare groups.

• Transfer to other programs.

Recovery In Focus is able to

transfer some graduates to

another treatment program;

some can also go to a work

release program.

• Specialized program positions.

The WCI Village program has

had difficulty recruiting

Hispanic staff. One of their

Hispanic program graduates,

while waiting to be released,

has been able to help fill this

gap. She has translated their

program manual and procedures into Spanish and now

teaches Spanish to women in

the program. She may next

offer Spanish classes to the

entire prison population.

• Institution jobs. WCI Village

has been able to place program

graduates in prized institutional office jobs, like receptionist

positions. This gives the

women job experience and is a

visible sign to inmates in general about advantages of being

in the program. However, the

project director cautions that

the correctional staff may need

training about how to interact

with these program graduates.

Initially, the correctional staff

overreacted by giving the

women gifts, treating them as

“special,” and engaging in

enabling behaviors. 

Stage 3:

Transition/PreRelease Planning

Research and experience identify

the first 90 days after an offender’s treatment and release from

custody as posing the greatest

risk of relapse, “when clients are

exposed to drug-related stimuli,

without the support of a structured program to help resolve

their conflicts” (Leukefeld and

Tims 1988, pp. 1-7). Pre-release

planning for this transition period is absolutely critical for

women offenders. As one project

director put it, “Many of our

women clients cannot make it on

their own [in the community].

We must identify these women

and get them proper help and

resources before they leave.”

Case Management in

the Pre-Release Period

Throughout the correctional

treatment process, two important

themes are (1) to motivate the

woman to enter community

treatment and to involve herself

in 12-Step or other mutual-help

groups after her release, and (2)

to identify the social, economic,

and vocational problems that

need to be resolved to help the

woman remain drug- and crimefree. Case management and

planning in the final weeks

before the woman’s release need

to focus on, and advocate for,

actual links to services. Major

links involve:

• Connections and individualized

planning with probation and

parole officers, so that correctional requirements can be met

and, whenever possible, the

parole process will reinforce

treatment goals.

• Connections and individualized

planning with community

treatment providers, so that

there is continuity between a

woman’s in-custody treatment

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

108
and the treatment she receives

in the community.

• Connections with local service

networks, so that the woman

has the ancillary services she

needs. The most important of

these are safe and drug-free

housing, child care for her children during her treatment,

vocational training and jobhunting assistance, and economic help until she is

employed.

The director of the North

Rehabilitation Facility suggests

that the planning process with

the woman should not be a

checklist-type operation. It needs

to be an in-depth exploration of

what the woman feels she needs

to remain drug- and crime-free.

She recommends that this

process involve a housing case

manager, a mental health specialist, a person expert in financial

and welfare aid, treatment beds

available on contract, and a

strong job/vocational component.

Access to care is a universal problem for women, unless they’re

pregnant. (The message this may

send to women is that they’re

only important in their maternal

function, not as a person.)

Transition From

Prison Programs

For the CSAT-supported prison

programs described in this Guide,

there is a strong transition planning component that operates

through the State’s corrections or

community punishment departments. This transition phase is

supervised through probation

and parole functions and, in

some States, continuing treatment is mandated for some or all

of the women being released.

Many women offenders’ pressing need for services comes after

this transition phase, when they

are in the continuing care phase.

The transition phase is structured

as follows for the CSAT prison

grantee programs:

• Oregon. Women can leave the

Recovery In Focus program

only to go to community treatment programs—either residential or outpatient. The State

corrections department puts

women on probation/parole

into treatment, with costs

picked up by the Oregon

health plan or by the counties,

using CSAT block grant moneys. There are correctional

treatment beds in the counties

and also resident and outpatient work release facilities

(until recently, there were nine

work-release beds for women

at the Multnomah County

YWCA). For compliant women

with long sentences, there is a

structured program that combines work release, job search,

and outpatient treatment. The

In Focus program follows the

women for 30 days, and a transitional specialist monitors the

women for the 6 months of

work release. Volunteer mentors then work with the

women during the aftercare

period (up to 1 year), reporting

to the transition specialist.

• California. Women in the Forever Free program are encouraged to volunteer for postrelease community treatment,

with a program placement goal

of 50 percent. Multi-funding

sources are available, including

a component from the California Department of Alcohol

and Drug Programs, which targets four southern California

counties and contracts with

nine residential treatment facilities. A new referral component,

recently funded by California’s

Department of Corrections

(DOC), now provides treatment dollars for placement

within any California county or

licensed treatment program.

The primary objective is placement in a full-time residential

treatment facility for up to 6

months. Two full-time staff—1)

a DOC employee who is a

Parole Agent, and 2) a contract

employee who is a Recovery

Advocate—dedicate their time

to transitioning participants

into community treatment.

Forever Free reports that it is

essential for the client to be

transported directly to the residential facility upon release.

Transportation is always scheduled or provided directly by the

Parole Agent.

• Delaware. Delaware, a small

State, has been restructuring its

correctional system to provide

a continuum of services for

substance-abusing offenders.

This continuum will provide

treatment and supervision at

all stages, from detention

through in-custody treatment

to structured work-release and

supervised aftercare. The WCI

Village TC for women is one

element in this evolving, integrated system. Treatment

Alternatives for Safer Communities (TASC) provides a

case management function for

the WCI women, both before

and after they are incarcerated.

The Delaware transitional

work-release component is

described in the next section.

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

109
• Arkansas. Choices staff, part of

a new community punishment

facility, conducted an education

effort with judges and parole

administrators. The court now

orders women into treatment

for a minimum of 90 days, and

the women may select the

Choices program. There are

post-prison transfer board

orders and judicial transfers to

the Department of Community

Punishment (DCP) if a woman

is eligible for treatment. Some

orders extend into the community, with treatment recommendations passed on to

parole officers. The DCP pays

for substance abuse treatment,

mental health services, and

general equivalency diploma

(GED) preparation. This is

done through DCP contracts

with statewide substance abuse

and mental health providers

across the State.

Only outpatient treatment is

available for women in Arkansas.

Since there is just one drug-free

living center for women in the

State, many women are returning to undesirable living situations. Choices staff work with the

women’s families whenever possible to gain their support for the

women. 

Transition From Jail Programs

For the CSAT women’s jail programs, the transitional period

after release tends to have less

systemwide structure than for

prison programs. The jail programs tend to be more involved

in actually developing and running post-release services for the

women. Since so few residential

treatment facilities are available,

housing for the women is a central issue. In addition, the jail

programs often maintain a continuing support function, setting

up support groups and other

ongoing activities for their graduates.

The Stepping Out program in

San Diego has a particularly comprehensive strategy to prepare

women for the post-release transition period. This program

includes the following components:

• Staff from treatment programs

in the area come to the jail on a

monthly basis to talk about

their programs.

• Staff from these community

programs come into the jail to

screen the women for entry

into their programs.

• A staff person from the community treatment facility

where the woman will be

going meets with the woman

and her in-custody case manager before the woman’s

release; the client and this staff

person mutually agree on her

community treatment and

make a personal commitment

to this treatment.

• For women going to outpatient

treatment, Stepping Out

arranges and pays for 30-45

days of living in a drug-free

environment, either through

their own houses or through a

San Diego network. Housing is

subsidized only if the woman

is in treatment.

• For women going to residential

treatment, there is often a waiting period of several weeks

before a treatment slot

becomes available. Stepping

Out develops an interim plan

for this waiting period that

includes housing in a drug-free

living house and outpatient

treatment.

• The aftercare program connects the women with a network of other services. This

network includes community

service agencies, employment,

and acupuncture. A planning

forum of service providers

takes place during the 1 week

before and 1 week after each

woman’s release. This forum

identifies and prioritizes the

woman’s needs. Primary needs

are delivered first. These

include clothing, food, housing, and personal hygiene

products.

• The women are picked up by

car and taken to their new

treatment settings.

Important Principles in

Transition Planning/

Supervision

The women’s programs described in this Guide offer a number of strategies for dealing with

key issues in the pre-release

phase.

Issue 1: Voluntary vs. mandated participation in community

residential/outpatient treatment 

Although some women offenders are currently mandated to

post-release treatment, many are

not. The reality is that, on a voluntary basis, a great number of

women offenders who need

treatment do not get it. For example, at the OPTIONS county program in Philadelphia, all women

who leave the treatment center

are given referrals to community

agencies. However, only 45 percent actually attend treatment. At

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

110
the Forever Free prison program,

where all the women are encouraged to enter community residential treatment, one-half of the

graduates choose to enter residential treatment; some also

enter community outpatient

treatment. At the Baltimore

detention center, all women are

encouraged to enter community

treatment. About 25 percent of

the women are sentenced to

prison instead of being released

at the time of trial. Of those

released, roughly 47 percent go

into community treatment.

Two of the CSAT programs

report good results in raising the

percentage of women entering

community treatment. Stepping

Out made a real effort to prepare

women for the transition into

other treatment programs, not in

the abstract, but in the transition

to the particular program that the

woman will be entering (see the

description above). These efforts

have reduced the attrition rate.

The Baltimore program is having

excellent results in increasing the

number of women in treatment

by means of a new court-based

project, a special project of the

Alternative Sentencing Unit. This

project offers sentencing inducements for entering treatment

combined with intensive case

management and outpatient

treatment. 

Clearly, a higher percentage of

women offenders engage in community treatment after their

release when treatment is

mandatory rather than voluntary. They also stay longer in

treatment. With this population,

mandating treatment along with

supervised sanctions, such as

regular urinalysis, may be the

most effective way to promote

recovery and a crime-free

lifestyle. But the move toward

more universal mandatory treatment for women needs to be

done with full awareness of the

ethical and possibly legal issues

involved. For example, is it ethical to force women into mandatory treatment for longer periods

of time than their crime would

otherwise exact? Another ethical

issue relates to the scarcity of

community residential treatment

facilities for women. As a society,

we certainly don’t want to have

to incarcerate women because

that’s the only place where they

can receive adequate treatment.

CSAT’s TIP 17 on planning treatment for adults in the criminal

justice system (CSAT 1995a)

offers an overview of these ethical issues. 

Issue 2: Critical importance

of immediate placement

Upon release, the women need

to go immediately to their treatment centers. As the In Focus

director points out, “Even waiting a few hours, you can lose

them.” One of the CSAT-supported programs experienced a tragic

example of this. A program graduate agreed to enter residential

treatment in her community but

she wanted first to spend the

weekend with her boyfriend.

That weekend she died of a drug

overdose.

Several of the CSAT-supported

programs physically transport

women to their new treatment

facility. These programs include

the SISTER project, Stepping

Out, In Focus, and Forever Free.

The Recovery In Focus program

recently lost the use of the State

cars used by staff to take women

to their new treatment sites

across the State. The program

now makes arrangements for the

women to travel by bus, and

their new treatment provider will

be there waiting at the bus stop

to meet the woman when she

reaches her destination.

Issue 3: Waiting lists

Once a woman is released, she

should go directly to treatment. If

there is a waiting list, then an

interim plan needs to be devised.

At Stepping Out, such a plan

would include safe housing,

ongoing supervision, acupuncture, and short-term treatment

support. 

Issue 4: Handling relapse 

Addiction is a chronic condition.

As anyone who has tried to give

up smoking knows, it may take

several or numerous attempts,

with lapses between, to completely give up cigarettes. These

women can be expected to have

lapses and relapses. Relapse prevention therapies have become

increasingly concrete and adept

at training people to recognize

their own personal cues of

impending lapses and to cope

with them. The SISTER project

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

111

Once a woman is released,

she should go directly to treatment.
devotes time 5 days a week to

work on coping with relapse.

In some jurisdictions, probation and parole officers receive

special training in how to case

manage women with addiction

problems. Probation/parole officers, if they are knowledgeable

and skilled, can be instrumental

in helping paroled offenders

weather relapse episodes. What

is needed when a woman relapses is to increase the level of services. However, many jurisdictions do not take this approach.

Instead, they use relapse as a

technical reason to return a

woman to custody. The CSAT

grantees suggest the following

strategies:

• Work with both the woman’s

community treatment provider

and the probation/parole officer. Both should get the same

paperwork—the woman’s

assessment, relapse prevention

plan, and the prognosis.

• Make sure each woman leaves

with a specific relapse-prevention plan that lays out the

behavioral specifics crucial to

her in recovery. Both the

woman and her parole officer

can then recognize the signs

that she is needing extra help.

• Have a personal conversation

with the woman’s probation/

parole officer; the officer must

make sure that the woman

becomes connected to Alcoholics Anonymous (AA), Narcotics Anonymous (NA), or other

mutual-help group meetings.

At Choices, each woman’s probation/parole officer is sent her

discharge summary and program recommendations, along

with the information given her

about local AA/NA contacts.

• Give the woman, before she

leaves, a list of names and

addresses for AA/NA support

groups in her area and ask the

woman to attend. At jail programs, a person from local AA

or NA chapters can visit and

make contact with the woman

before her release. This is a natural contact if the jail already

has mutual-help group meetings at the facility.

Issue 5: Integrating in-prison

treatment with communitybased care

It is very desirable to have a continuum of treatment planning

between the in-custody program

and the community program.

The CSAT grantees have used a

number of strategies to link their

programs with community treatment and other services. These

include the following strategies:

• Invite treatment providers to

come into the facility to screen

women clients for the program, and work with them to

develop a coordinated ongoing

treatment plan for each individual woman. In Focus,

Stepping Out, and the

Baltimore Detention Center all

do this.

• After obtaining consent of the

client, provide the new treatment provider with detailed

paperwork and other communications about the woman.

• Share training and cross-training events with community

providers.

• Look for opportunities to work

as a team; an example would

be the forums that Stepping

Out holds before and after a

woman’s release to identify

and prioritize her needs.

• Bring community service representatives into the facility to

tell about their services. The

OPTIONS program, for example, in 3 years has had 145 seminars given by 70 community

representatives from many different agencies and disciplines.

Issue 6: Mobilizing women to

enter treatment programs

Motivating women to want to go

into community treatment is a

theme of the short- and mid-term

in-custody programs, as already

explained. But when it comes to a

woman’s actual decision, in the

critical pre-release period, CSAT

grantees suggest several strategies. Most strategies reflect the

fact that the women are frightened and in crisis; they need to

feel that they will be safe. Women

offenders want to know where

they will be going, how they are

going to be treated, who will be

the people involved in their

treatment, and what will be

expected of them.

• Bonding with the new caregiver.

Most critical is that the woman

gets a chance to meet a person

from the new treatment program. Stepping Out says that

this needs to be a personal

bond. The In Focus program

has found that, since community treatment providers have

come to the prison to do their

screening and to meet with

each woman client ahead of

time, the length of time that

women stay in community

treatment is lengthening.

• Making a one-to-one commitment. The new caregiver needs

to get a commitment from the

woman client, a promise about

the appointment. “We’re

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

112
Chapter 6—Stages in the Treatment/Accountability Continuum of Care

113

counting on you for next

week.” The staff member from

the new program also must

make a commitment to the

client. “Yes, I’m the one who

will be there for you.”

• Visiting the new program. One

project manages to arrange for

a woman client to make a visit

or to spend a weekend, so the

woman can see the new program in advance and meet

other participants. This is also

helpful if the woman is going

to a work-release center. 

• Meeting child care needs.

Whether the woman goes to

residential or outpatient treatment, she will have to resolve

child care issues first. One project has arrangements for child

care through women in an

Oxford House. (The Oxford

Houses are a national network

of self-run, self-supported

recovery houses for individuals recovering from alcohol or

drug addiction; see “Program

Materials” in the Resource List

for the address of Oxford

House, Inc.) The SISTER project offers a legal liaison who

advocates for the woman

regarding custody issues. This

legal advocate also prepares

women for their court appearances and advocates to get the

women into treatment instead

of jail or prison. 

Stage 4: PostRelease Treatment

and Continuing

Care

The prison and jail demonstration programs described in this

Guide are designed to serve

women in custody. For women

offenders with serious, long-term

drug abuse problems, in-custody

treatment offers a valuable window of opportunity for motivating the woman into substance

abuse treatment. The period of

incarceration provides a period

of relative stability, giving

women the breathing space to

look at themselves and their

addictions and to begin the difficult process of changing their

lives. 

In-custody treatment can be

critical for these women.

However, this treatment and

supervision is only the beginning. Practitioners agree that

women offenders must have

help during the transition to

community life. Most women

offenders with substance abuse

problems successfully manage to

be abstinent and drug free during the structured jail or prison

period. Remaining abstinent in

the community, without any

structure and while facing myriad personal and economic problems, is much more difficult.

Women’s program directors on

the CSAT expert panel stressed

that women offenders with drug

problems are not receiving the

structure, support, and time they

need to rebuild their lives after

leaving the institution.

The experience of the CSAT

grantees supports the conclusion

of a number of experts—that one

of the most feeble links in the

criminal justice system is the connection between rehabilitation

efforts in prison and the process

of integration into society after

release (Wexler and Williams

1986). A national 1992-93 mail

survey of jail and prison programs that provide drug treatment and other services to

women offenders found that

more than 90 percent of these

programs encouraged women to

begin or continue attending 12-

Step meetings, and more than 80

percent said they made arrangements for continued care in the

community. But fewer than half

of the prison and jail programs

reported providing other transition services from custody to the

community, such as housing,

income, medical care, or followup contacts (Prendergast et al.

1995).

The Bureau of Justice

Assistance has concluded that

“women have a more difficult

time integrating into the community after release than men

do. This is because women are

likely to be at a more advanced

and severe stage in their substance abuse when they are

incarcerated, and because

women suffer from a broader

range of problems, including

more medical and mental health

problems, educational deficits, a

lack of vocational skills, and

more complicated family and

community relationships” (BJS

1994).

Women offenders must have help

during the transition to community life.
Chapter 6—Stages in the Treatment/Accountability Continuum of Care

114

Components for PostRelease Transition to the

Community

A broad range of concrete experience with addicted offenders

suggests that, in the period after

release from prison or jail, the

person with a history of chronic

drug use will need the following

components:

• Continuing treatment for drug

abuse. This may be primary

treatment subsequent to an incustody motivational program,

or less intense continuing

treatment for those who

received primary residential

treatment while incarcerated.

The principle is that the

offender continues in treatment, at ever decreasing levels

of intensity, until the person’s

recovery and crime-free

lifestyle are stabilized. Most

programs plan a process lasting 6 months to a year.

• Probation/parole supervision.

Regular urinalysis is an important part of this supervision, to

ensure that the offender

remains drug free and to trigger immediate help for a

relapse. It is an enormous

advantage to have ongoing

treatment required as a sanction by the criminal justice system during this period.

One Federal research demonstration project designed to

offer highly intense case management and outreach to

offenders during post-release

concluded, “Without an external force making sure they

attend [treatment] when first

released from prison, there is little that can be done to help

clients internalize the motivation to stay in treatment and to

stay clean” (Martin et al. 1995).

For this research project, the

inability to require participation

in treatment—either as a means

for early parole or as a condition

of parole—severely impacted

on retention (Martin and

Scarpitti 1993).

• Case management to ensure

services. Case management is

critical for providing coordinated services at transitions

between stages of the justice

system. Case management

needs to provide a way of linking the treatment and criminal

justice systems, ensuring that

offenders meet both their criminal justice and treatment

requirements. Case management services have also been

found to enhance retention in

community treatment among

drug-involved offenders, an

outcome that is closely linked

to reduction in recidivism

(Hubbard et al. 1988). In addition, a case manager is needed

to link the women with other

needed services.

Those in residential treatment will have their housing

and other needs met while

they are in treatment. But after

release, and for women who

go from custody directly into

outpatient treatment, there are

immediate, pressing needs for

such services as medical, dental, and mental health care;

child care and assistance in

maintaining custody; housing;

educational and vocational

training; legal aid; and assistance in obtaining any potential entitlements, such as

Medicaid and public assistance. 

• Participation in mutual-help

and support groups. The follow-up studies show that the

addicted offenders who

remain longest in treatment—

the group most successful on

parole—also have the highest

participation in AA, NA, and

other mutual-help groups.

These groups serve as therapeutic bridges from incarceration to the community. Relapse

prevention is a major concern

for recovering addicted clients,

and a supportive group of nonusing peers is clearly an important asset. Other appropriate

mutual-help groups for

women offenders could

include Women for Sobriety,

Survivors of Incest Anonymous (SIA), or Rational Recovery. However, these groups

are not a form of treatment,

and attendance at meetings

should not be used as a sanction (CSAT TIP 17, 1995a).

Various Paths for Women

Upon Release

Research suggests that community-based aftercare is necessary to

reinforce the primary treatment

initiated in prison. Women need

a continuum of care upon release

into the community. Table 12

shows the various paths that a

woman may take, depending on

the individual’s need, the intensity of treatment received in custody, and the care available in the

community. The type of treatment provided should, if at all

possible, be consistent with the

treatment philosophy used in the

corrections treatment program.

Major paths are described on the

following pages.
Chapter 6—Stages in the Treatment/Accountability Continuum of Care

115
Chapter 6—Stages in the Treatment/Accountability Continuum of Care

116

Residential Treatment,

Including Residential

Community TCs

Women with severe, chronic

AOD problems will benefit most

by transferring from correctional

treatment into supervised treatment in a community residential

setting. The program should

serve women only. Outcome

data support the value of a reentry TC for reducing both drug

use and criminal recidivism.

Some research suggests that TC

treatment during the transition

from prison to the community is

the most influential component

of the prison TC/community TC

continuum (Martin et al. 1995,

p. 115).

For some women offenders, a

residential program for mothers

and their children will be desirable. TC models for women only

are often not available. TCs that

serve mothers and their children

are even more scarce (Brown et

al. 1996). Three model programs

are Par Village, St. Petersburg,

Florida, a collaborative research

and demonstration project

between Operation PAR, Inc. and

the University of South Florida

Psychiatry Department; Amity,

Inc., in Tucson, Arizona, and the

Prototypes Women’s Center in

Pomona, California.

Intensive Outpatient Treatment

Intensive outpatient treatment

can be as effective as residential

treatment for some addicted

women offenders, and it may be

the most intense treatment

option available in some communities. The women should be

treated in women-only groups,

rather than in coed settings. Also,

outpatient treatment needs to be

combined with supervision, case

management, and safe and drugfree housing arrangements.

Women-centered, intensive outpatient treatment is even more

desirable when the woman’s

children can be included.

Work Release Facilities

Work release is a correctional

program in which incarcerated

offenders are allowed to leave a

correctional institution or facility

during daytime hours to work,

attend school, obtain treatment,

or pursue other purposes identified by correctional officers. Drug

testing is often required.

Outpatient substance abuse

treatment can be available as part

of the program or may need to be

arranged as an adjunct to it.

Delaware is unique in having a

TC work-release center; this center serves both men and women

offenders.

Work release programs are

quite common, but they can be

less effective for women than for

men, because women have significant treatment and habilitation needs that cannot be

addressed in this setting (Illinois

Criminal Justice State Plan

Working Group 1995). Treatment

experts point out that work

release programs do not provide

an appropriate continuity of care

for offenders following in-custody substance abuse treatment.

This uncontrolled environment

“can do much to undo progress

in the in-custody treatment program by throwing the recovering

clients abruptly into an environment that is contaminated with

the outside influences of the

street—the drugs, the violence,

and the attitudes and values that

militate against rehabilitation”

(Scarpitti et al. 1993).

Work release programs should

offer women the chance to continue their recovery efforts while

learning job skills and gaining

employment experience. Recovering women need to receive simultaneous AOD treatment and to be

separated from the general population. Women-only programs are

an advantage. A sample study of

women in Delaware found that

although the women appreciated

the chance to work, about 60 percent indicated difficulties related

to being a woman within a predominantly male work release

program (Miller 1990).

TC Work Release

Delaware has developed an

innovative program called

CREST that combines a TC program and a work release program (see description below).

CREST is located on the other

side of a wall from Delaware’s

traditional work release program

for the general prison population. The program serves both

men and women offenders who

have drug-abuse problems. This

TC initially provided the primary

drug treatment for women

offenders, who had no TC available in prison. Since the startup

of the WCI Village TC, CREST

has become a transitional TC for

Village graduates. The treatment

providers now recommend a

women-only work release TC,

rather than a coed program, as

being more suitable for their

women Village graduates.
Chapter 6—Stages in the Treatment/Accountability Continuum of Care

117

Day Reporting Centers

Treatment programs at day

reporting centers allow women

to participate in rehabilitation

programming during the day

and return home at night. Drug

testing is often required.

Programs that are designed to

serve women will provide or

arrange for extensive services,

including substance abuse treatment, life skills training with

ancillary counseling, child care,

parenting education and observation, and employment. Each

participant will have an individualized treatment plan. Women

participate in activities for 4 to 10

hours daily. Women awaiting

their trial dates, as well as sentenced offenders, can both utilize

day treatment programs.

Though the CSAT programs

did not have access to day reporting centers, this is a promising

model. Day centers can provide

daily supervision, urinalysis, parenting assistance, and the other

services needed by recovering

women in one location (the “onestop” model).

Illinois has set up program

models in the community for

women—day reporting centers

and a family unity demonstration project—in which women

can receive the types of treatment in which they can be successful under Department of

Corrections supervision. These

programs are expected to be less

expensive and more effective

than in-prison treatment (Illinois

Criminal Justice State Plan

Working Group 1995).

Halfway Houses

A halfway house is a residential,

transitional living arrangement

in which residents are supervised

by paid staff. Residents may

work and receive education,

training, or outpatient treatment

in the surrounding community,

although some treatment may be

provided in the house. The

women share house responsibilities and must follow rules. The

length of stay may be limited or

unlimited, and depends on the

woman’s attaining her specific

progress goals.

Halfway houses are important

because they give women a safe

and sober place to live so they do

not have to return to the environment in which they lived

before incarceration. At halfway

houses, residents are under constant supervision during initial

placement and later transition

into the community. Regular

urine monitoring is conducted,

and positive urines may result in

violations and reincarceration.

Some people with drug abuse

and criminal histories can control

their drug use while they remain

in a tightly structured halfwayhouse environment. However,

unless they also receive drug

treatment, many of these offenders cannot control their drug use

once they leave this structured

environment. A study in

Delaware showed that, if these

offenders do not receive residential treatment, they are unable to

maintain abstinence after release

from the halfway house. Only 32

percent of such offenders (that is,

substance-abusing offenders

who go to a halfway house but

do not receive any residential

treatment either in prison or

afterwards in the community)

are still drug-free at 6-month follow-up. This compares to 91 percent drug-free status among

offenders who participated in a

prison TC and a transitional

work release TC (Peyton 1994,

pp. 15-16). It is recommended

that, for women drug offenders,

gender-specific treatment be

included with halfway house

supervision. 

TC Work Release: A New

Approach

Upon their release from prison,

WCI Village graduates go to

CREST, a 6-month work release

program operated by Correctional Medical Services. This is

the only program in the country

that combines a TC with a work

release program. It is an 80-bed

program that serves 12 women

and 68 men. This model is of

interest, because it combines the

advantages of TC treatment with

a structured program of work

release, regular urinalysis, and

participants’ graduated levels of

responsibility during release to

the community. A research study

reporting on this program shows

Halfway houses are important because

they give women a safe and sober place to live

so they do not have to return to the environment

in which they lived before incarceration.
Chapter 6—Stages in the Treatment/Accountability Continuum of Care

118

that men who go through the

combined multistage prison/

work release TC have very positive outcomes. Eighteen months

after release from prison, 76 percent of these men were still drug

free and 71 percent were arrest

free. In comparison, only 19 percent of a control group receiving

no treatment were drug free and

30 percent were arrest free.

Outcomes are not yet available

for women who go through the

combined WCI Village and

CREST programs.

The Delaware work release TC

includes the following phases:

• Phase 1: 2-week orientation,

involving induction into the

TC, assessment, and evaluation.

• Phase 2: 8-week component,

emphasizing involvement in

the TC community, such as

participation in morning meetings, community jobs, group

therapy, individual counseling,

confrontation, and nurturing.

Phase 2 residents are encouraged to begin engaging family

members in the treatment

process through family and

couples groups led by CREST

counselors.

• Phase 3: 5-week component,

stressing role modeling and

supervision of other clients

with assistance of staff.

• Phase 4: 2-week component,

preparing the women for transition from the TC community

to the outside community, with

mock interviews, resume

preparation, and seminars on

job seeking.

• Phase 5: 7-week reentry component, including obtaining and

maintaining employment outside the TC, finding appropriate housing, and preparing for

the final recovery stage of living

independently. Residents open

a bank account and begin to

budget for housing, food, and

utilities (Lockwood 1992).

Women who have been

through the WCI Village TC proceed faster through the program

than those without prior TC

experience. The biggest difference is in the two early phases,

when the WCI Village women

already know about TC principles. In all phases of treatment at

CREST, urine is monitored on a

regular but unscheduled basis.

After the last work release

phase, graduates are free to live

and work in the community.

Most have probation or parole

stipulations to follow. CREST

provides a 6-month “aftercare”

component to ensure that graduates fulfill their probation and

parole requirements. The aftercare component provides a

reduced level of continued treatment services to combat the risk

of relapse and recidivism. The

aftercare component requires the

woman to be totally abstinent

from drug and alcohol use, to

attend one 2-hour group session

per week as well as individual

counseling, and to continue with

urine monitoring. Graduates

must return to the work-release

TC once a month to serve as role

models for current CREST

clients. The women are encouraged to participate in 12-Step

programs. The women also have

access to an aftercare support

group through WCI Village.

The considerations and issues

to resolve in setting up a TC for

work release are discussed in several articles written by authors

from the University of Delaware

Center for Drug and Alcohol

Studies (Lockwood 1992; Inciardi

et al. 1993b; Lockwood and

Inciardi 1993).

Issues Concerning

Treatment in the

Community 

The CSAT prison demonstration

programs have encountered gaps

in the services available for

women on their return to the

community. Programs report that

their greatest challenge has been

the difficulty of linking clients

with community-based aftercare

following their release. The network of services is fragmented

for women, with varying gaps

depending on the particular

State or community. Communities, for example, may offer a

number of outpatient treatment

programs serving women but not

have available residential care for

mothers and children. Women

receiving community outpatient

treatment are often unable to

find safe and sober housing.

Some of the most critical challenges emerging in the link-up to

community treatment are the

lack of access to treatment beds,

the dropout rate among women

who enter community treatment

programs, and the great diversity

among community programs.

The most cost-effective treatment

for offenders is a system that can

match a woman to the type and

length of service she needs. Incustody treatment programs can

only make this kind of match for

their clients if they have in-depth

information about the available

community treatment programs—and if an appropriate
Chapter 6—Stages in the Treatment/Accountability Continuum of Care

119

program is accessible and has

beds or treatment slots available.

Second, women coming out of

fine in-custody treatment programs are in danger of losing

their gains if they can’t be linked

to community treatment programs. This programming is critical to ensure continued benefits

for the women and thereby to

improve public safety. 

Issue 1: Lack of access

The reality is that many of the

CSAT-supported programs cannot find enough community

treatment slots for their women

graduates. They make full use of

what is available. In some places,

only outpatient treatment is

available for women. Residential

treatment for women with children is scarce. This very spotty

availability of community treatment facilities for women offenders is a national problem. The

number of available slots for

women offenders is far short of

demand, particularly for women

who are pregnant, have children,

are mentally ill, are homeless, or

have a history of violence

(Prendergast et al. 1995). The

treatment that is available does

not necessarily offer the types of

services that returning women

offenders need.

The shortage of transition services becomes glaringly apparent

to State agencies when they

assess their custody/community

continuum for offenders.

Delaware, for example, found

that no one—no system—was

fully responsible for druginvolved offenders until the

Treatment Access Committee

(TAC) was established in 1992

(Peyton 1994). This lack of system

responsibility was true even

though well over half of

Delaware’s offenders were drug

involved, and over half of all people in drug treatment were

offenders. Delaware found that

all the outpatient and residential

treatment slots available

statewide for all Delawareans

were inadequate to meet the

needs of just the criminal justice

population (Peyton 1994, p. 21). 

However, the state of treatment facilities specifically

designed for women is steadily

improving. Enormous gains have

been made over the past decade.

CSAT has sponsored a number of

multi-agency criminal justice initiatives across the country, and

these are creating better treatment opportunities for women.

For example, the OPTIONS TC

program in Philadelphia has

recently gained access to community treatment slots through a

multi-agency criminal justice

effort for early parole called the

Forensic Intensive Recovery

(FIR) project. Many of these slots

are designed to meet the specific

needs of female substance-abusing offenders.

Another important boost to

women’s programming has come

through the Federal substance

abuse prevention and treatment

block grants. In 1992, States were

required to set aside a portion of

these funds for specialized

women’s programs. The upshot

has been the creation of many

more women-specific programs

across the country than were

available even 5 years ago.

Pennsylvania, for example, now

has a statewide network of 16

licensed long-term residential

treatment programs for pregnant

and parenting women and their

children, plus 35 other licensed

programs that specialize in treating this population.

The Center for Substance

Abuse Treatment (CSAT) has

recently conducted two extensive

demonstration programs for substance-abusing women and their

children—the Residential Treatment Services Grants for Pregnant and Postpartum Women

and Their Infants and the

Residential Treatment Grants for

Women and Their Children.

Women involved in the criminal

justice system have been successfully treated in these comprehensive programs. CSAT found that,

of women referred to these

women’s residential programs by

the criminal justice system, 81

percent had no new charges following their treatment (CSAT

1995b). 

Issue 2: High dropout rate

Poor retention of women clients

in community treatment programs is a widely reported problem. The Forever Free program

undertook a pilot study to investigate how their program graduates fared in the months after

their release back to the community (Prendergast et al. 1996). At 1

to 11⁄2 years after their release, the

researchers interviewed a small

pool of Forever Free graduates

and a comparison group of

women offenders who had been

barred from participating in the

Forever Free program for logistic

or administrative reasons.

Findings from this small study

are tentative, but suggest some

compelling conclusions about the

post-release status of these

women. The study looked at
Chapter 6—Stages in the Treatment/Accountability Continuum of Care

120

their drug use and parole outcomes, treatment experiences

while on parole, their various

needs, and whether the women

were able to meet those needs.

Longer times in community

treatment translated to better

outcomes, but most women

dropped out early. Of 48 Forever

Free graduates who (voluntarily)

entered a 6-month community

residential treatment program, 17

(35 percent) left the program

within the first 30 days, with 12

of them leaving within the first 7

days. Among the 19 interviewed

women, fewer than half (8)

remained in treatment for more

than 3 months, which research

has found to be the minimum

length of time in treatment necessary for significant program

effects to be observed

(Prendergast et al. 1996). As for

being successful on parole,

involvement in residential treatment made a difference:

• A quarter of the comparison

group who did not participate

in the Forever Free prison program were successful on parole

(23 percent of this comparison

group entered outpatient treatment after release to the community).

• Half of Forever Free graduates

who did not enter community

residential treatment were successful on parole (30 percent of

these graduates entered outpatient treatment after release).

• Two-thirds of Forever Free

graduates who entered community residential programs

were successful on parole.

• 86 percent of Forever Free

graduates who stayed in residential treatment for 5 months

or more were successful on

parole, compared to 58 percent

of those who remained in residential treatment for less than

5 months (Prendergast et al.

1996).

Issue 3: Diversity among

treatment programs

Those who operate correctional

programs need to know specifics

about individual treatment programs in the communities where

women clients will return. The

Forever Free study found “vast

differences in the programming

and policies” of the eight community residential facilities

entered by their graduates.

Community treatment facilities

are often small, stand-alone facilities; these programs are quite

diverse and operate on a variety

of models. Among the questions

to ask are: what components and

services does each program offer,

what referral sources are used,

and what has been the outcome

success with different types of

clients?

The Prendergast et al. study

(1995) of corrections and community treatment programs nationwide found that programs vary

considerably with regard to

which services are offered and

whether particular services are

offered on-site or through referrals. He concluded that few if any

programs—whether located in

the community or in a jail or

prison—are able, at the site, to

provide all the services that

women need. 

TASC is a model in which

expertise is present in AOD, criminal justice, and other service systems. Case management across

systems requires competency in

those systems.

Issue 4: Continuity in treatment approach

Each of the CSAT-supported

women’s jail and prison programs operates under a coherent

program philosophy about

addiction and how to treat this

problem in women. The program

directors point out how important it is for women to move from

their correctional treatment program to a community program

that has a similar philosophy. A

woman may be confused and

lose ground if she has to shift

from one treatment philosophy

and environment to a program

operating on different assumptions. Achieving continuity with

the post-release treatment was a

common problem among the

programs. Some of the issues

encountered by the CSAT

grantees were:

• The difficult adjustment for

women who must go to traditional male-dominated community programs from womenfocused prison programs. When

outnumbered by men in treatment, many women tend to

focus on meeting the men’s

needs instead of dealing with

their own. To overcome longtime patterns of physical,

social, and/or emotional abuse,

women need a continued

focus on these issues and on

personal empowerment.

• The disconnect for women who

go from jail or prison TCs to traditional community treatment

programs that are 12-Step oriented. Because there are few

community TCs available for

women, women offenders may

be moving from a correctional

TC to a 12-Step oriented program in the community. Even
Chapter 6—Stages in the Treatment/Accountability Continuum of Care

121

though many prison TCs may

incorporate 12-Step principles,

the overall models are very different. This makes for a discordant and confusing transition,

instead of a continuum of care.

In the CSAT program, several

of the correctional TCs modified for women are beginning

to develop their own aftercare

components to provide continuity.

• The problems of moving from a

women-specific TC to a coeducational TC. This happens in

Delaware with women going

from WCI Village to a coeducational work release TC, where

the women constitute about 20

percent of the client population. Some of the work-release

TC staff are women, but the

majority of staff are men.

The approach is very confrontational. The TC environment is therefore very different

from what the women experienced at WCI Village.

Village treatment staff say the

women need their own TC. It is

difficult to avoid male/female

relationship issues in such close

quarters, and women have

been expelled for “flirting.” The

women [participants] also tend

to focus their attention on the

men’s issues, rather than on

their own concerns.

The program director at WCI

Village states that women

come out of this prison treatment program as much

stronger people. But the

women need additional time

to work on their own independence and addiction issues.

The women are not ready to

enter a coeducational setting

immediately on release from

prison. 

Case Management

in the Community

When a woman offender returns

to the community, a number of

systems—at a minimum, corrections, Federal- and State-funded

substance abuse treatment, and

social services—need to coordinate and communicate with each

other. Who makes the treatment

decisions? Who makes the decisions about sanctions? Who is

responsible for seeing that the

woman’s many needs for shelter,

employment, child care, and

relapse prevention are being met?

In setting up a case management function for women

offenders, it is important to identify who will have specific

responsibility for the woman and

who will make the treatment

decisions. The points of accountability between the criminal justice and treatment systems need

to be clearly defined, with some

method set up for timely reporting to both systems. The roles for

the involved agencies should be

stated in written agreements.

This will involve memorandums

of agreement and cross-training

for AOD treatment agencies and

the criminal justice system.

The hub for this crucial case

management function can be in a

variety of places—with probation

officers, with the treatment

provider, with an independent

organization like TASC. Table 13

provides a summary of different

approaches for handling the case

management function. The

important factor is that some

entity, and some individual caseworker, be responsible for supervising each offender after her

release. 

Need for Intensive

Case Management

Case management with recovering women offenders does not

mean making referrals. It entails

coordinating the entire system of

care for the woman, including

her parenting and custody problems. Ex-offenders also require

an intensive level of outreach

beyond what treatment

providers and parole officers are

accustomed to providing. This

can mean that the worker physically goes “to the park bench” to

talk to the client. Some programs

are beginning to use an intensive

and promising case management

model from the mental health

field, called Assertive Community Treatment (ACT).

The ACT case management

model is based on a holistic

approach that involves all needed support systems and treatment modalities, determined on

an individual basis for each mental health client. Multidisciplinary teams, with one team

member acting as a coordinator

for each client, provide services

24 hours per day, every day, on

an unlimited basis. The ACT system is designed to encourage

client independence and functioning in adult social and

employment roles, to meet the

basic needs of mental health

clients, and to lessen the family’s

burden in providing care.

This ACT case management

model has been specifically

applied to high-risk druginvolved parolees through a

demonstration grant supported

by the National Institute on Drug

Abuse (NIDA). The reports on

this model provide a number of

ideas about the barriers—and the
incentives—of using a case management model for promoting

continued community treatment

among this population (see

Inciardi et al. 1992; Martin et al.

1995). With this model, counselors had difficulty doing adequate outreach in the parolees’

neighborhoods, and the parolees

showed low motivation to stay in

substance abuse treatment.

Counselors in this demonstration

agreed that the backing of the

criminal justice system was needed to compel clients into treatment, and that treatment personnel cannot function as both treatment counselors and intensive

case managers.

Case Management for

Prison Parolees During the

Post-Release Period

It is clear that women offenders

with long-term drug problems

need a whole range of coordinated services during the period

after release from prison. In most

States, the women in State prisons will be drawn from a broad

geographic area. It is essentially

impossible for a prison treatment

program to be the hub providing

these continuing services. The

case management function needs

to be passed on to some other

system operating at the community level. For the CSAT prison

programs, these linkage mechanisms include:

• WCI Village: Coordination

passes to the transition work

release component; WCI

Village graduates go to a work

release TC with urinalysis

where supervision is provided

by treatment rather than security staff and TASC is involved

in coordinating aftercare. 

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

122

Table 13. Selected approaches for case management

1. Case management provided by the justice system. In this model,

justice system case managers are assigned caseloads at specific

stages of the system, such as probation or parole. An advantage of

this model is that the criminal justice system has “ownership” of the

case management process. Justice system officials are invested in the

process because their own staffs are implementing it and reporting

back to them. A major disadvantage is that this process can be expensive.

Some jurisdictions have probation/parole officers especially trained to

act as case managers for substance abusing offenders. This method

can be extremely effective, but officers need small caseloads. Today’s

average caseload for probation/parole officers is 120 offenders—far

too many to permit effective case management of addicted women

offenders.

2. Case management provided by a treatment agency. This model is

community based. One advantage of the model is that the case manager has a thorough understanding of the AOD treatment process. The

disadvantages include the expense and the possibilities that the case

manager may not be familiar with the criminal justice system or that

the AOD treatment agencies may not have the resources for effective

case management.

3. Case management provided by an agency separate from the

treatment and justice systems. To reduce costs, this model could

employ a case management coordinator, with or without a caseload, to

conduct intake interviews and supervise paraprofessional staff. The disadvantages of this approach include the addition of another agency to

the collaboration and expense. TASC is a successful example of this

model.

4. Case management provided by a coordinator from the justice

system who provides consulting services and technical assistance to support existing criminal justice case management. One

advantage of this model is system ownership. A coordinator, with or

without a caseload, oversees the work of a paraprofessional staff. The

coordinator can move the criminal justice system toward a greater

awareness of treatment issues by providing technical assistance that

demonstrates service coordination.

5. Case management provided by multidisciplinary groups in the

criminal justice system for offender management. This type of

group may meet regularly and during crises. This model is the most

inexpensive. However, it is the most difficult to successfully operate

because no one is assigned overall responsibility for the offender.

—Excerpted and adapted from Center for Substance Abuse Treatment, Planning

for Alcohol and Other Drug Abuse Treatment for Adults in the Criminal Justice

System. Treatment Improvement Protocol (TIP) Series, No. 17. DHHS Publication

No. (SMA) 95-3039. Rockville, MD: Substance Abuse and Mental Health Services

Administration, 1995a, p. 49.
• Recovery In Focus: The coordination function passes to a

Department of Corrections

transition specialist, who coordinates treatment and services

along different paths. For

women going to work release,

the transition specialist

arranges for a hook-up to outpatient treatment close by.

During the work release period, the woman is supervised,

goes to two 12-Step meetings

per week, and has a urinalysis

every day.

• Forever Free and Choices programs: Through their Departments of Corrections and

Community Punishment, community probation and parole

officers become the organizing

hub for coordinating treatment

and parole.

Case Management of Jail

Releasees in the Post-Release

Period 

Because the women clients are

local, jail treatment programs can

physically provide a focus for

coordinating treatment, relapse

prevention, and social services

after a woman’s release. However, this solution has some

inherent limits. Program staff is

of a finite and stable size. The

number of women who successfully pass through a jail program

and then need services over time

will continue to grow. A 2-week

program, such as the Baltimore

Awareness and Acupuncture

program, literally serves hundreds of women a year. There are

obvious logistical limits to a program’s ability to provide and

manage the transition treatment

and aftercare for such large numbers of women.

Case Management Strategies

by CSAT Jail Programs

In Baltimore, a new case management program for women has

been set up under the CSAT

Target Cities program. This program occurs through the

Alternative Sentencing Unit

(ASU), which provides treatment

inducements in lieu of incarceration. Many of the 2-week program graduates now receive case

management and supportive

services through the ASU. The

treatment path after a woman’s

release includes:

• Initial participation by clients

in an intensive day treatment

program at the Johns Hopkins

Hospital’s Comprehensive

Women’s Center.

• Graduation of the women to

less intensive care based on

attendance, evidence of drug

abstinence, and progress on

their treatment plan goals.

The Baltimore ASU provides

intensive case management by

specially trained ASU employees

who coordinate substance abuse

treatment, medical, psychosocial,

and other service resources. This

new program is having a positive

impact on increasing the number

of women who enter community

treatment following the detention center program.

The longer jail programs serve

a smaller total cohort of clients.

When there is no communitybased system to case manage the

women’s housing, treatment,

and aftercare, the CSAT-supported programs have set up their

own services to meet the gap.

• In the OPTIONS county jail

program, an outreach coordinator is assigned to develop

linkages with community

agencies. The aim is to encourage these agencies to deliver

services within the jail, as well

as to arrange for treatment

slots as referral sources for

clients after their release.

• In the Stepping Out jail program, a holistic continuum of

care is provided through the

Community Connection Resource Center’s extensive service network for offenders in

San Diego county. (Stepping

Out is managed through this

agency.) The services include

sober living houses, intensive

outpatient treatment, job

development and placement

assistance, referrals to supportive services, clean and sober

recreation, and an agency

mutual-help group.

• In the SISTER project, a limited number of women can

receive follow-up residential

treatment at Walden House or,

if pregnant, at Jelani House.

The program is developing

new initiatives to help women

unable to access these limited

resources. The focus is on finding the women safe housing

and some access to outpatient

Chapter 6—Stages in the Treatment/Accountability Continuum of Care

123

It is clear that women offenders with long-term

drug problems need a whole range of coordinated

services during the period after release from prison.
Chapter 6—Stages in the Treatment/Accountability Continuum of Care

124

treatment, and on setting up

alumnae and support groups.

The program tracks clients

after they leave and loops

them back to the program

through continuing care, to

ensure reintegration and continuing support. 

Women’s Need for

Continuing Services

Although the number of women

in the pilot research study of

Forever Free graduates was small

(Prendergast et al. 1996), this

study gives real insight into the

needs that addicted women

offenders experience when they

return to the community—and of

the extent to which these needs

may go unmet. The women were

interviewed 12 to 18 months after

being released to parole and

were asked “During the past

year, what help or services did

you need for yourself and/or

your children? Did you get assistance for this need?” All three

groups studied—Forever Free

graduates who entered residential treatment, graduates who did

not enter residential treatment,

and the comparison group of

addicted women who had not

experienced the Forever Free

program—reported having the

same needs, although their rankings were somewhat different.

Identified Needs of Women ExOffenders in the Community

After “help with preventing

relapse to alcohol/drug use,” the

most often mentioned needs by

women offenders in the Forever

Free study were:

• Getting employment (58 percent)

• Getting help with Supplemental Security Income (SSI)

and Aid to Families with

Dependent Children (AFDC)

(56 percent)

• Getting treatment for alcohol

and drug use (47 percent of

those not in residential treatment listed this need)

• Self-esteem and living skills (42

percent)

• Medical or dental exams and

treatment (38 percent)

• Housing (36 percent)

• Food, furniture, clothing,

household supplies (28 percent)

• Education programs, GED (27

percent)

• Transportation assistance (25

percent) 

• Spiritual or religious support

(23 percent)

• Psychological counseling (23

percent)

Issue 1: Providing for help

with relapse prevention.

The women’s high perceived

need for help in preventing

relapse is one of the key findings

from the pilot study of Forever

Free graduates and untreated

offenders done by UCLA and the

California Department of

Corrections (1995). Women who

were not in residential treatment

listed the need for help in preventing relapse to alcohol and

drugs as their number one need

over 25 other categories. While

almost 2/3 (64 percent) of the notreatment comparison group listed this need, so did 63 percent of

the Forever Free graduates who

entered residential treatment.

Among women in residential

treatment, 6 of 8 (75 percent)

reported that they got assistance

for this need. Of Forever Free

graduates who did not enter residential treatment, just 1/3 (2 of 6)

received help with preventing

relapse. Among the comparison

women, only 1 of 9 women (11

percent) received any help.

Issue 2: Unmet needs of

women after residential

treatment.

The leading need reported by

Forever Free graduates who had

entered residential treatment

was for employment help (79

percent). Only 57 percent of the

women who had entered residential treatment reported that

they got employment assistance.

Only 2 of 6 women needing help

with SSI, AFDC, and food stamps

actually received such help. The

reason for the lack of help is not

clear, but it may reflect the fact

that some of the residential programs do not have an aftercare

component or that women who

dropped out of residential treatment early did not receive aftercare services.

Issue 3: Unmet needs of

women receiving no community

treatment.

Among the women not in a community residential program, it is

noteworthy that half (47 percent)

said they needed treatment for

alcohol and drug use. Their two

top reported needs were for

relapse prevention and employment. Only 3 of 15 women listing

relapse prevention as a top-rated

need actually received help; only

2 of 14 women needing assistance with employment actually

received it. One of the main reasons that women said they were

unable to get specific needs met
Chapter 6—Stages in the Treatment/Accountability Continuum of Care

125

was because they did not know

how or where to get services for

the need. The study team concluded that “little assistance was

forthcoming in the community to

those women who had not had

the services of the communitybased residential treatment”

(UCLA Drug Abuse Research

Center and California DOC 1995,

p. 41).

The experience of Forever Free

graduates is fairly typical. Being

in community treatment—either

residential or outpatient—is no

guarantee that a woman offender

will receive help with the services she needs. A recent survey of

336 programs nationwide that

serve women offenders found

that many do not arrange for

ancillary services (Prendergast et

al. 1995, p. 246). Concerning two

of the most critical—safe housing

and finding a source of income—

programs reported:

• Mixed-gender outpatient programs—24 percent arrange for

adequate housing before treatment is completed; 27 percent

keep women in treatment until

a source of income is obtained.

• Women-specific outpatient programs—53 percent arrange for

housing and 37 percent make

sure a source of income is

obtained.

• Women-specific residential programs—83 percent arrange for

housing and 56 percent ensure

a source of income.

Although, on a percentage

basis, fewer outpatient than residential programs help clients

with housing, these percentages

may be misleading in terms of

the absolute numbers of women

who are helped. Typically, residential programs serve much

smaller numbers of clients and

for longer periods of time than

outpatient programs. Thus, outpatient programs may actually

help the larger number of

women clients with housing.

Issue 4: Providing for safe,

drug-free housing.

CSAT program grantees report

an almost total absence of

halfway house facilities for

women after their release from

custody. The Choices program—

at a new facility in Arkansas—

points out that the entire State

has only one sheltered apartment

for women with children.

Choices program graduates can

be released only if they have

some place to live. The women

may not want to return to living

situations with drug-using relatives or friends, but often there is

no other option.

The Jail Substance Abuse

Program in Washington County,

Maryland, a rural area, found

that the lack of available structured housing for their female

program graduates was a major

factor in the higher rate of recidivism among women as compared to male offenders (C.R.

Messner, personal communication 1996). Their informal statistics based on a small group of

women clients showed that

women who had access to

halfway house facilities were

more likely to succeed in staying

out of jail. In their jail program,

only 25 percent of women program graduates who were admitted to the supervised halfway

house facilities returned to jail.

Other women graduates could

not be admitted to the halfway

house for lack of space, and 90

percent of these women graduates returned to jail.

Strategies for Providing

Services

Strategies for Providing Safe,

Drug-Free Housing

As already discussed, finding

safe and drug-free housing for

women after their release is very

difficult. Halfway houses are

much less available for women

than they are for men, and few of

those that are available can

accommodate children. As one

program director pointed out,

“Women can be classified as

homeless when they leave mental institutions, so they get housing on a priority basis. Housing

would be much easier if women

could also be classified as homeless when they leave prison or

jail.” 

The SISTER project director

recommends working with the

local housing authority and identifying funding sources. It may be

possible to arrange housing

through section 8 or to get a

housing priority status for the

women in public housing.

Another possibility is to assist

women in setting up an Oxford

House. There are currently 87

women’s Oxford Houses nationwide. These houses are run, paid

for, and lived in by recovering

clients, who may stay as long as

they remain drug- and alcoholfree and abide by the group

rules. The national Oxford House

headquarters can provide information on how these houses are

structured and managed (see the

Resource List). 
Chapter 6—Stages in the Treatment/Accountability Continuum of Care

126

Some of the ways used in the

CSAT programs to provide safe

housing include these:

• The SISTER program arranges

for residential treatment for

women offenders, and for

pregnant women, through

Walden House, Inc. Walden

House operates a number of

satellite women’s shelters,

where SISTER graduates can

stay. Support groups are available through the Walden

House residential programs.

• For In Focus graduates, some

housing was once available at

the YWCA in conjunction with

the Oregon Department of

Corrections work release program. Although this resource is

no longer available for the In

Focus program, it represents

an interesting, practical strategy that others may find worth

exploring.

Modifying Oxford Houses for

Mothers and Children

As the Choices and SISTER

project directors both point out,

there is a pressing need for

halfway houses for women who,

after being stabilized, can be with

their children. However, women

who set up in their own apartments or are in an Oxford House

situation still need a case manager and a variety of supports. As

one director stated, “The woman

gets her own safe apartment and

the next thing you know, her

drug-addicted brother has

moved in with her and she’s

right back in that drug-using

environment.” Women caught in

such circumstances need to break

from their earlier family relationships and attachments, which is

extremely difficult.

Only five Oxford Houses

nationwide admit women with

their children. Experience suggests that the rules for these

houses need to be modified and

that the amount of caseworker

support is considerably greater

than for adult houses. The kinds

of issues that need to be looked at

include:

• Size and cost of the house. With

children needing bedrooms

and play space, the houses

need to be larger than those

housing only adults. Also,

there will be fewer resident

adults to pay the rent than in

all-adult facilities.

• Number and relationships

among children. The number of

families needs to be assessed

carefully, to avoid possible conflicts among the children and

the mothers. A very preliminary suggestion, based on one

Oxford House for mothers and

children, is that no more than

two families—combined with a

few women without children—may be a workable configuration.

• Parenting skills of the mothers.

The very limited Oxford

House experience to date suggests that the mothers need

ongoing help in developing

their parenting skills.

• Guidance on budgeting. The

mothers need help on budgeting their limited funds. Even

though they have sufficient

funds to pay the rent, the

mothers tend to spend the

money instead on high-quality

clothes, video games, and

other items for their children.

• Development of new rules. An

Oxford House mother with

children who relapses can’t be

thrown out of the residence at

3:00 a.m., as would be usual in

these houses. Who would be

responsible for the children?

These types of issues simply

show why supervision and

support need to continue during the months that a woman

is stabilizing her recovery and

becoming self-supporting.

CSAT Program Strategies for

Preventing and Controlling

Relapse 

The Stepping Out program recommends building on the

women’s strengths—even if the

women don’t think they have

them. For example, many of the

women have great strengths in

terms of nurturing and perseverance. They need to be encouraged to continue to attend

women’s Alcoholics Anonymous

(AA), Narcotics Anonymous

(NA), Cocaine Anonymous (CA),

and other support groups. In

addition, the women need to

have particular individuals they

can turn to for help and support

when they need it. Several of the

programs have set up support

groups and other methods of

providing one-on-one help.

Some of these include:

• Freedom 1st mutual-help group.

At Stepping Out, a mutualhelp group is available that

was created by and for exoffenders. Stepping Out alumnae can attend this support

group for ex-offenders sponsored by the program operator,

Community Connection Resource Center.

• Alumnae group. The SISTER

program is starting an outpatient alumnae group that

will meet in the evenings. The
Chapter 6—Stages in the Treatment/Accountability Continuum of Care

127

SISTER project plans outings

with program alumnae and

staff to bring the group

together for fun and continued bonding.

• Alumnae support group. The

SISTER program is also developing a SISTER support group

for alumnae, with names to

contact when a woman needs

to talk.

• Winners Circle. This is a voluntary peer support group set up at

WCI Village. The group offers

each woman a person she can

call if she fears relapse.

Winners Circle is a mutualhelp support network for substance-abusing offenders. Started

in Connecticut, the Winners

Circle concept has been adopted

in several States and is growing

into a national movement. A

Winners Circle chapter can be

integrated into the program of

TCs or other residential programs in correctional facilities. It

is designed to offer addicted exoffenders a chance to meet regularly to discuss common issues

and engage in problem-solving

strategies within a supportive

environment. 

* * * * * *

Technical assistance, training,

and videotapes, as well as written materials, are available for

setting up a new chapter of

Winners Circle. For information,

contact the CSAT Systems

Development and Integration

Branch, Criminal Justice Project

Office (telephone 301-443-6533).

* * * * * *

CSAT Strategies for Ongoing

Support 

In Oregon, the In Focus project

uses a volunteer women’s mentor program to provide a supportive role model for women in

their communities during the

aftercare phase. Although outcome statistics are not yet available, a similar women mentor

model in New York State has

demonstrated great success in

reducing recidivism among

women ex-offenders. This program, called WomenCare, has

matched 218 volunteer mentors

with women ex-offenders

(“mentees”) over a 6-year period.

The mentees are home from

prison, where they participated

in drug rehabilitation programs;

about 75 percent are single parents. The WomenCare program

reports a recidivism rate of just 3

percent among women offenders

in its program (D. Breslin, personal communication, 1997).

The Recovery In Focus program is involved in matching up

the personality of each woman

graduate to a mentor in her

home community. The mentor

stays in contact with a woman for

6 months to a year after the transitional work release/treatment

phase. Mentors report back to the

transition specialist.

The mentors make a minimum

6-month commitment and go

through extensive training with a

resource treatment specialist. The

mentors need training to understand about setting boundaries

and supporting women who

have both a criminal and a substance-abusing background. It is

a major commitment for the

mentors. If the mentor comes

from a 12-Step mutual-help

group, she needs at least 5 years

of sobriety to qualify. Mentor volunteers have been bank employees, retired workers from the

Child Services Division, and

members of community churches. The In Focus director believes

that the structured transition and

aftercare component is a major

factor in success of the program

graduates.

Both the prison and the jail

programs have events that help

their graduates maintain contact

and give them recognition for

successful recovery. Some of

these activities include:

• Annual celebrations for alumnae. Recovery In Focus recently honored a graduate who

had completed 4 years in successful recovery. As previously

discussed, a number of the

programs have these annual

celebrations. 

• Return opportunities. At the

OPTIONS program, women in

stable recovery come back to

the unit, chair NA meetings,

and offer recovery seminars to

active clients.

• Continuing activities. All

CREST graduates are urged to

return to the facility periodically, to participate in the groups,

the one-on-one interactions,

family sessions, and retreats

that represent the final stage of

prison-based TC treatment in

Delaware.

129

Chapter 7—Critical Issues in

Implementing Programs 

E

very substance abuse

treatment program—no

matter in what setting—

faces operational challenges. Such challenges

range from the need to maintain

community support and funding, to how to locate and recruit

skilled staff, to setting up ways to

attract appropriate clients.

Programs in criminal justice settings share some particular and

unique challenges. Critical issues

include the need to:

• Engage in a systematic planning process that covers not

only the program itself, but the

relationship between the incustody treatment program,

the correctional system, and

treatment in the community

• Select an appropriate treatment approach and good programming principles

• Gain and/or maintain the support and understanding of the

prison or jail administration

and the on-line security staff

• Select and train both the security and treatment staffs

• Set up good working relationships with the institution’s

medical/psychiatric staff

• Establish a plan for providing

continuous quality improvement and evaluation.

This chapter highlights what

the CSAT women’s program

grantees suggest about how to

handle these issues. Other program planners may find it helpful

to know what kinds of difficulties

the grantees have encountered in

implementing their women’s

programs, as well as the strategies

and methods they are using to

resolve these issues successfully.

Engaging in a

Systematic

Planning Process

Those interested in developing a

drug treatment program for

women in a correctional facility

need to go through a systematic

planning process. With the help

of a number of practitioners and

experts in the field, the Center for

Substance Abuse Treatment

(CSAT) has compiled a manual

titled Critical Elements in

Developing Effective Jail-Based

Drug Treatment Programming

(CSAT 1996a). This manual, available as publication number PHD

729 from the National Clearinghouse for Alcohol and Drug

Information (NCADI), provides

chronological guidelines on the

following critical elements pertinent to both women’s and men’s

treatment programs:

Stage I: Pre-Planning

Assessment 

1. Identify resources

2. Identify costs and benefits

3. Study legislation and regulations

4. Identify possible barriers

Stage II: Planning and

Program Development

1. Determine jail or prison population profile

2. Write a mission statement

3. Develop a support base

4. Select a treatment approach

5. Develop a strategy for continuity of care

6. Develop a screening and

referral system

7. Design an information tracking system

8. Develop policies and procedures

9. Plan and conduct training

10. Foster interagency partnerships

11. Establish an ongoing continuous quality improvement

and evaluation program 
Chapter 7—Critical Issues in Implementing Programs

130

Selecting an

Effective Approach

Choosing an effective approach

is the most critical basic task in

designing treatment for addicted

women. Good treatment is

designed to address women-specific issues, and good programming addresses issues directly

related to the women’s substance

abuse behavior. Chapters 2, 4,

and 5 in this Guide provide a

framework for making choices

about program design.

What does experience suggest

works best in programming for

women offenders? The experience of the CSAT women’s

prison demonstration programs

is consistent with earlier findings

concerning what works in treating women offenders. In a

nationwide study of innovative

strategies and community programs for female offenders,

Austin et al. (1992) concluded

that the most promising strategies often used the “empowerment” model of skill building to

enhance the women’s coping

and decision-making skills and

enable them to achieve independence. 

The study found that effective

therapeutic approaches are multidimensional and deal specifically with women’s issues, such as

alcoholism/addiction, parenting,

relationships, gender bias,

domestic violence, and sexual

abuse. The following characteristics appeared to influence successful program outcomes:

• A design that provides for a

continuum of care

• Program expectations, rules,

and sanctions that are clearly

stated and uniformly enforced

• Consistent supervision

• Diverse and representative

staffing

• Coordination of community

resources

• Access to ongoing social and

emotional support

• Multidimensional approaches

that deal with women’s issues

specifically

This Guide focuses on issues

that are specific to treating

women offenders. However,

there are many established principles for effective AOD treatment programs that apply

regardless of whether men or

women are being treated. Table

14 summarizes these generic

principles, based on a broad

review of the experience of a

number of jail and prison treatment programs (Peters 1993, pp.

17-19). 

Gaining Support

From the Prison

Administration

Introducing intensive substance

abuse treatment into a corrections setting requires meshing

two different systems that often

have differing goals and philosophies. The overall environment

in a prison or jail can be supportive for treatment or it can be nonresponsive, setting up a series of

structural, physical, and emotional barriers for a treatment

program and its clients. Those

setting up new programs for

women will obviously need to

work within the basic climate of

the particular institution.

It is important to be aware that,

in the past, some custodial officers have distrusted TC staff and

operations and have deliberately

sabotaged treatment programs

(Camp and Camp 1990; Inciardi

and Scarpitti 1992). One potential

source of resistance can come

from correctional staff who have

alcohol problems themselves.

Because alcohol problems occur

among people in all segments of

U.S. society, such resistance is

commonly encountered by alcohol prevention and intervention

programs across all American

institutions, be they school systems, workplaces, or prisons

and jails.

The literature makes clear how

important it is to gain administrative support for correctional

treatment programs (Peters 1993,

p. 17). For CSAT women program

grantees, experience has been

mixed but positive. Some

grantees received enthusiastic

support for their programs and

an understanding of treatment

needs from the beginning.

Others have had to work hard to

educate the administrators and

to advocate for the needs of their

women clients. These grantees

report that it took about 2 years

to overcome institutional barriers

and to make fundamental

changes needed by the programs. Two of the grantees had to

struggle against sabotage efforts

by various levels of correctional

staff.

Support is important at two levels: from administrators at the top

and from the overall institution,

particularly on-line security staff.

Situations are so varied it is hard

to generalize, but it appears that

women’s treatment programs are

likely to face the greatest obstacles

when they are in traditional maleoriented correctional settings
Chapter 7—Critical Issues in Implementing Programs

131

Table 14. Principles of effective treatment with offenders

Reviews of the literature and of substance abuse treatment programs within the criminal justice system indicate

key principles that are associated with successful treatment of offenders (Andrews and Kiesling, 1980; Bush et al.

in press; Falkin et al. 1990; Gendreau and Ross 1984; Leukefeld and Tims 1992; and Wexler et al. 1988a).

These principles, drawn from experiences in implementing both jail and prison treatment programs, are briefly

summarized below.

1. Develop commitment from jail administrators to support the substance abuse treatment program and to

provide adequate staff and technical resources.

2. Use a coordinated approach in the design and implementation of the in-custody substance abuse

program, involving both substance abuse and custody staff.

3. Conduct cross-training for substance abuse treatment staff, custody staff, and key administrators to review

the program philosophy, inmate management techniques, policies and procedures, and other common areas

of interest.

4. Provide a treatment unit that is isolated from general population inmates. This strategy tends to remove

participants from the corrosive influences of the jail/prison subculture and encourages development of

prosocial behaviors and group cohesion.

5. Provide incentives and sanctions to encourage inmates to enter and complete in-custody treatment programs.

6. Develop a sequence of in-custody treatment services that is consistent with the expected length of

incarceration.

7. Provide comprehensive assessment examining an inmate’s treatment needs, risks presented to the

institution (e.g. suicidal or aggressive behavior), and level of supervision required. Match inmates to treatment

services according to the results of this assessment.

8. Develop a structured treatment environment. An intensive array of in-custody program services tends to

encourage self-discipline and commitment to treatment, and is necessary to address the many skills deficits

and areas of psychosocial dysfunction among this population.

9. Provide clear consequences for inmate behavior within the institutional treatment program. Positive

and negative consequences for inmate behaviors should be clearly indicated. Program rules and guidelines are

reinforced through a system of formal and informal sanctions.

10. Encourage sustained participation in substance abuse treatment. Institutional programs of less than

3 months duration should develop procedures to ensure that inmates are placed in supervised aftercare

treatment within the community.

11. Provide multimodal treatment services. Treatment activities should address the range of psychosocial

problems and areas of skills deficits that may inhibit successful recovery from drug and alcohol dependence.

12. Encourage identification and modification of criminal thinking patterns, values, and behaviors.

Program counselors systematically model and reinforce prosocial behaviors within the treatment unit. Clearly

defined sanctions are provided for antisocial behaviors.

13. Employ cognitive-behavioral treatment techniques. Self-management strategies such as cognitive

restructuring and self-monitoring should be addressed in treatment programs. Opportunity should be provided

for modeling, rehearsal, and overlearning of these techniques.

14. Involve inmates in skills-based interventions. Programs should encourage the acquisition and rehearsal of

drug-free and prosocial skills to deal with interpersonal problems, stress, anger, and other personal, parental,

and professional challenges faced during recovery.

(Table continued next page)
Chapter 7—Critical Issues in Implementing Programs

132

where the institution’s philosophy focuses on punishment and

control. For jail programs, the

Sheriff’s department philosophy

and orientation in the hiring and

training of deputies will affect

how supportive and accepting the

correctional staff is toward a treatment program.

In some correctional institutions, understanding and support

for substance abuse treatment can

be very strong. Two CSAT

grantees, the Forever Free and

Choices programs, report particularly positive support from their

institutions. In both cases, the

institution is headed by a female

warden who is committed to

rehabilitation goals for the

women offenders. In addition,

Choices—a new community punishment facility in Arkansas

where residents can move about

freely on the grounds—is

designed to be a rehabilitation

facility; the security guards are

called “residential supervisors”

and wear nontraditional uniforms (khaki pants and blue

oxford shirts). The officers wear

regular uniforms at times when

they oversee residents who are

performing community service.

Also, the way correctional

treatment programs are structured can produce close and reinforcing ties across systems, with

all entities perceiving success of

the treatment program as a

shared mission. The Forever Free

program at the California

Institute for Women in Frontera,

California, is one example. The

women’s treatment program is

coordinated by two agencies—

the Office of Substance Abuse

Programs in the California

Department of Corrections

(CDC) and the State Department

of Alcohol and Drug Programs

(the CSAT grantee).

In this coordinated structure,

the CDC Office of Substance

Abuse Programs provides: (1) the

overall grant project director and

evaluator; (2) a correctional counselor who provides project oversight, is responsible for screening

and selection of program participants, and is the liaison with

institutional management staff

and parole services; (3) a correctional counselor who handles

case management, classification,

and disciplinary issues; and (4) a

Table 14. Principles of effective treatment with offenders

(continued)

15. Provide training in relapse prevention techniques. Exercises should promote awareness of individual

relapse patterns, including warning signs, high-risk situations, and covert setups. A range of coping skills

should be provided to anticipate the high rate of relapse among drug-involved offenders. Opportunities should

be provided to rehearse these skills in the institutional treatment program and during aftercare.

16. Involve inmates in “core” group treatment experiences. Involvement in a primary treatment or therapy

group provides a catalyst for behavior change. This behavioral change is achieved through reinforcement of

the client’s progress toward recovery and the confrontation of her denial and resistance. Group treatment also

provides a cost-effective vehicle for educational and skills-based interventions.

17. Provide pre-release planning and assist program participants in the transition to aftercare services.

Successful in-custody substance abuse treatment programs help to coordinate placement in follow-up treatment

services. Most program participants are in need of at least 1 year of follow-up treatment and regular drug testing

that is provided within the context of probation or parole supervision. TASC-like agencies have proven to be particularly useful in linking offenders to community treatment and in monitoring compliance with aftercare treatment.

18. Develop measures to assure accountability to short- and long-term program objectives. Evaluation

strategies are implemented in the early stages of program development. Evaluation should include process,

impact, and outcome measures.

—Excerpted and adapted from Treatment in jails and detention settings, by R.H. Peters. In: Drug Treatment and Criminal

Justice. Thousand Oaks, CA: Sage Publications, 1993.
parole agent who serves as the

continuity of care coordinator.

This parole agent is responsible

for assuring that program participants make a smooth transition

from custody into the community and that the women stay in

treatment for as long as possible

while they are on parole. The

subcontractor—Mental Health

Systems, Inc.—operates the incustody treatment program and

provides the project manager

and counselor staff. The State

Department of Alcohol and Drug

Programs provides funding for

the women’s post-release community treatment. 

For treatment programs, it is

important to build communication, understanding, and support

not just with the top administrators but throughout the entire

institutional setting. These efforts

need to be ongoing. Two key

areas that need continuing attention include:

• Differences that arise from the

differing responsibilities and

roles of treatment and correctional staff. At the North

Rehabilitation Facility, for

example, the correctional staff

has been involved with treatment for 15 years in integrated

treatment/security situations,

yet staff says there are still differences to be worked out.

Even the vocabularies may be

different, with the women

being “offenders” to one system and “clients” to the other. 

• Lack of understanding about

principles of treatment, especially treatment in therapeutic

communities (TCs). Corrections

staff may perceive treatment as

“coddling” the inmates. Some

corrections staff may have difficulty adapting to the client

autonomy and control inherent in the TC models.

According to Pan et al. (1993),

TCs implement techniques and

strategies that challenge the

routines of highly organized

prisons. 

Natural bureaucratic resistance can arise either from suspicious or willful individuals,

from sheer organizational

rigidity, or both. These authors

suggest that this type of resistance is very difficult to overcome unless the TC modality is

supported by high-level staff.

* * * * * *

For a clear discussion of the

underpinnings and differences in

perceptions between the corrections and treatment systems, see

CSAT TIP 17: Planning for Alcohol

and Other Drug Abuse Treatment

for Adults in the Criminal Justice

System (CSAT 1995a).

* * * * * *

Program Planning Phase

Creating a supportive relationship between the institution and

the treatment staff needs to start

at the very beginning—when

initial plans are made for a program. Usually a correctional

facility provides treatment services by contracting with an outside agency. In some cases, the

correctional facility has designed

the treatment program before

the person who will run that

program becomes involved. The

expected project director needs

to be included early in the program planning, so that person

can work cooperatively with the

decision-makers at the correctional facility and with any other

agencies to be involved.

As was discussed earlier, there

are a number of treatment models. Once a given model has been

decided on, it can be very difficult if not impossible to make

fundamental changes in how the

program will operate. For this

reason, correctional institutions

need to be careful not to make all

the key decisions about the

model until after the project

director comes on board.

Institution policies and constraints may limit some desired

treatment options, such as the

ability to make 8 hours every day

available for treatment. All parties need to be working together

to find the best compromise.

In the planning stage, treatment staff need to look very carefully at the institution’s history,

especially at the correctional staff

who will gain or lose power and

position when the new treatment

program starts. One grantee

Chapter 7—Critical Issues in Implementing Programs

133

Creating a supportive relationship

between the institution and the treatment staff

needs to start at the very beginning—when

initial plans are made for a program.
Chapter 7—Critical Issues in Implementing Programs

134

stressed that, to avoid possible

undercutting and sabotage, it is

important to know about and

address any existing turf issues in

a frank manner and at the beginning.

The Stepping Out project

points out how important it is to

get input about program plans

from all affected personnel, particularly custody staff. Pivotal

custody staff positions, such as

sergeants and work assignment

deputies, need to work closely

with program designers and

operators from startup through

the life of the project. Without

the cooperation and buy-in of

key custody staff, a treatment

program will not operate successfully.

Sufficient startup time for a

new program is important.

Several of the CSAT-funded programs were expected to be up

and running within brief periods,

such as 1 month after their contract was awarded. This does not

allow enough time for the treatment staff to work with administrators in selecting and training

security officers for the program.

Neither is the time adequate to

develop or update needed curriculum materials or to recruit

and train the treatment staff.

Ongoing Relations

With the Institution

Two of the CSAT grantees commented that it takes a lot of work

to build and maintain their relationship with correctional staff,

but that this relationship continues to improve over time. Some

of the grantees’ suggestions for

building this acceptance for the

program include the following:

• Consistently try to involve the

administration in the program

process at every opportunity.

Promote the TC or other model

as a highly attractive form of

rehabilitation.

• Meet with the administration

on a regular, ongoing basis and

confront any issues immediately. Don’t let problems or conflicts linger unresolved.

• Be persistent and determined

about the needs of your program. As one project director

said, “They know I won’t be

deterred and I’ll keep calling.”

• Look for opportunities to

integrate treatment staff into

the institution as a resource.

As an example, the WCI

Village program now has a

senior counselor assigned to

the institution’s classification

board. This assures that

appropriate, eligible women

are being sent to the program,

but it is also providing a substance abuse specialist as a

resource for the institution. 

• Take advantage of any chance

to orient and train the entire

agency about the program. This

is a new direction that offers

promise. Such institution-wide

orientation would help with the

situation reported by one

grantee, where the staff felt fortunate to have two positive,

supportive security deputies

assigned to their program.

However, these two supportive

deputies did not represent

overall staff attitudes about the

program; these deputies experienced trouble with their peers

when the time came for them to

assimilate back into the institution’s overall deputy staff.

One of the grantees stressed

how essential it is to establish

clear lines of communication

within the institution. For example, program changes that affect

deputy duties must be communicated through the chain of command, not in a memo from the

program director to deputies. It is

important to hold regularly

scheduled meetings between custody staff, program operators, and

other concerned parties as often

as is practical and necessary. The

treatment program also needs to

have a designated staff person on

site at all times, or available by

telephone, who can respond to

any institutional concerns.

Selection and Role

Of Corrections

Security Staff

Security officers are significant

players in a woman’s treatment

unit, particularly in TCs or other

residential programs that operate

in a therapeutic milieu. Security

staff can be a positive force in

helping women heal. If they are

negative about the program or

the women in it, they can also

damage the treatment process.

One grantee reports their program experienced “sabotage and

undercutting.” According to this

grantee, “It was necessary to

facilitate transfers of key custody

people on the female unit in

order to implement services and

to penetrate the existing regime

and their antifemale inmate attitudes and behavior.” The CSAT

women’s programs, nearly all

TCs or intensive residential programs, share a set of consistent
recommendations about selecting security staff. They suggest

that:

• Many officers or deputies will

not be appropriate for the

treatment program. If at all

possible, the treatment staff

should be allowed to reject

those persons who are not

suitable.

• Training for security officers

will be necessary and should be

ongoing. Alternate or substitute staff must also receive

training.

• Security staff for the program

should be a regular assignment.

Rotating security personnel is

not desirable. 

The CSAT grantees believe

that either women or men

deputies can be equally successful. A supportive male deputy

can be a fine role model for the

women clients, many of whom

have primarily experienced abusive males in their personal

lives. As a result of their very

low self-esteem, these women

are sensitive to feelings of being

devalued. Deputies who are not

highly supportive of the treatment process can sabotage it.

One grantee pointed out that

negative, nonsupportive attitudes from any deputy can

undermine the women’s vulnerable sense of self-esteem and

their progress, but if that deputy

is a woman, the effects are especially bad. Women clients really

feed into the negativism coming

from another woman. In addition, a negative deputy can have

a divisive influence, splitting the

treatment group.

Functions of the

Security Officers on

Treatment Units

Some officer functions will be

determined by the particular institution. At some facilities, for example, the officers may accompany

the women for security reasons to

all their education, vocational, or

other sessions outside the treatment unit. In the CSAT women’s

programs—both TCs and others—

the officers are trained and available to support the women participants during evening and night

hours, when treatment staff are

not onsite.

The daytime functions

assumed by security officers in

the WCI Village program are fairly typical of TCs. The officers can

perform their share of tasks, have

a non-clinical role as part of the

group, and support the process.

They participate in the ongoing

life of the group but do not take

part in treatment sessions. In

other words, for confidentiality

and other reasons, the officers do

not sit in on groups where the

women are dealing with their

issues. 

Qualities of Corrections

Staff 

The North Rehabilitation Facility

finds that security officers who

are successful have an accepting

attitude toward addicted women

offenders as fellow human

beings; they are able to perceive

of the inmates as people, not

objects. In a pragmatic sense,

their officers want to help the

women become better neighbors

and citizens as a benefit to the

total community. Other desirable

qualities for custody officers to

possess include:

• Having a nurturing personality

• Being empathic and emotionally healthy as individuals

• Feeling comfortable with

inmate/client decision-making

• Having participated in a TC

themselves (an advantage in

TC programs)

The assigned security officers

will need to have cross-training,

which is described later in this

section. But in addition to that,

the treatment staff needs to provide clear guidelines and expectations for officers in TC settings.

The officers will need ongoing

guidance and individual interventions. For example, a new

officer in one of the short-term

TC programs was not allowing

the women to give each other

friendly hugs after treatment

hours.

The security officers’ behavior

needs to be consistent with treatment goals. Officers need to

understand and appreciate the

TC treatment process, so they can

be “on board” with treatment

staff in supporting and reinforcing the TC milieu. Officers need

to understand all the rules thoroughly, to enforce them consistently, and be careful not to bend

the rules. They need help in setting boundaries. Some officers

may simply not be oriented to

substance abuse treatment and

may need help in understanding

what a difficult process the

women are experiencing.

The CSAT-supported treatment programs have had some

limited experience with security

officers who are themselves

recovering from substance abuse.

Chapter 7—Critical Issues in Implementing Programs

135
Chapter 7—Critical Issues in Implementing Programs

136

Such officers understand what

the women participants are

going through, but they also

need training and other guidance.

Program staffs say that officers

who are recovering from substance abuse themselves can be

highly supportive of treatment

goals, contributing significantly

to a positive environment for

clients. On the other hand, such

officers can be unduly biased in

favor of their own recovery philosophy or may tend to monopolize the group’s attention with

their own personal recovery

issues.

The essential point here is that

security officers can be an integral, positive part of the TC community and treatment process.

However, all security officers—

even those in personal recovery

with a positive attitude toward

treatment—will need guidance.

Selection and

Training of

Substance Abuse

Treatment Staff

For corrections treatment programs, there can be debate about

which staffing model will be

more appropriate: the “professional” model or the “recovering

addict” model. The “professional” model calls for selecting staff

who are educated, trained, and

experienced in counseling, psychology, or social work. The

“recovering addict” model promotes the use of ex-addicts

and/or ex-offenders in key leadership and clinical positions

(Inciardi 1995). Counselors who

have professional academic

degrees earn higher salaries and

so cost more, but they generally

have trained clinical skills and a

detachment that may not be

found in the recovering addict

counselor. However, recovering

addict counselors are excellent

role models. They have developed coping skills, in terms of living in the community while

abstaining from drug use, that

can be helpful for drug-dependent offenders. Recovering counselors provide offenders with a

credible role model to which they

can relate (Bureau of Justice

Assistance 1991, p. 47).

The CSAT women’s grantees

are using two different staffing

patterns, depending on the type

and length of the program. For

the short-term intensive programs that focus on motivating

and referring women to appropriate treatment, it can be an

advantage to have staff with

professional degrees who are

clinically trained. All the other

programs—whether intensive

outpatient or TCs—use and recommend a staff/supervisor mix

of trained professionals and certified substance abuse counselors who are either recovering

or ex-offenders.

Staff for Short-Term

Programs 

The 2-week, intensive program

in the Baltimore Detention

Center uses a “professional”

model, with all clinical staff having at least a master’s degree.

This program is a motivational

model, designed to provide

intense, targeted help to women

and move them into appropriate

community treatment programs

and other services.

The short-term program at

North Rehabilitation Facility

combines addictions counselors

with professional clinical staff.

The project director points out

that, when a program has only 13

or 14 days to assess and motivate

the women, staff must be clinically astute. Among the skills they

need will be:

• A sound understanding of the

therapeutic models of developmental change for women

• The ability to assess where the

individual woman is on the

continuum of developmental

change and motivation

• An awareness of the wide

array of therapeutic tools available and a knowledge of how

to match those tools with the

“The selection of both correctional and treatment

staff is the crucial element for any program.

It is the attitude and energy of staff that make

the most notable difference in the outcome

of treatment efforts.”

—CSAT grantee
Chapter 7—Critical Issues in Implementing Programs

137

needs of a great diversity of

individual clients 

Staff for Mid- and LongTerm Residential

Programs 

The intensive, longer term

women’s programs depend on

certified substance abuse counselors, both recovering individuals and recovering ex-offenders,

as the backbone of their treatment staffs. Clinically trained

professionals—both staff and

supervisory personnel—help

support the treatment process.

The clinical staff are selected

for expertise in the areas most

targeted by the particular program. Programs commonly have

staff with special clinical expertise in screening and assessment,

mental health (particularly cooccurring disorders), and family

therapy. One program director

mentioned that it had been of

tremendous benefit for her to

have a clinical background, as

her program blended a medical

model of substance abuse with a

TC model.

In hiring certified counselors

who are recovering, programs set

certain criteria. The Forever Free

program, for example, requires

that counselors have been in

“sober and clean” recovery for a

minimum of 3 years, and they

may not be on parole, probation,

or under any other court-ordered

supervision. Some correctional

institutions have a policy that

forbids ex-offenders to be employed on staff. This problem can

often be overcome by having the

treatment contractor hire the exoffenders. However, the contract

staff will still have to pass security clearance checks. Corrections

will always do background

checks on anyone working in

their prison. Consequently,

obtaining the administration’s

buy-in with the program will be

essential if they will be asked to

waive restrictions on ex-offenders working in the institution.

Special TC Needs

TC models have special staffing

needs. It is imperative that TC

programs have some counselor

staff who have themselves experienced a TC program. Finding and

recruiting staff with this experience can be difficult, particularly

in parts of the country where few

TC programs exist. CSAT, through

its technical assistance initiatives,

may be able to provide some suggestions. Therapeutic Communities of America may be another

resource. Time needs to be allotted for this recruitment process,

because it may require a regional,

if not national, search. Some

strategies for expanding the available base of individuals with TC

experience are mentioned below. 

Attaining a Racial/Ethnic

and Gender Staff Mix

It is very important that treatment staff be ethnically and culturally diverse, approximating

the same mix as the women

clients. Just having a representative staff mix will not be sufficient, however. Programs need to

have a theme of cultural diversity

within the program, and staff

training will need to deal with

understanding the women’s cultural differences and sensitivities.

Several of the women’s correctional programs offer separate

group sessions by cultural grouping (such as Caucasian, AfricanAmerican, Hispanic, Asian

American, and Pacific Islander

groups) and by sexual preference

(such as groups for lesbian, bisexual, and transsexual women).

The issue of whether to

include men as staff counselors

in women’s treatment programs

is less clear-cut. The women’s

programs discussed in this report

have predominantly all-female

counseling staffs and point to

this as an advantage of their programs. There are valid reasons

for using male counselors, however. Among these are:

• The shortage of available

women counselors who have

experienced a TC and are

recovering and/or have come

out of the correctional system

themselves

• The value for the women

clients of working and interacting with a positive, supportive

male role model, who can

exemplify relationships in

which men do not assume

dominant, aggressive, and

abusive roles 

Male counselors, if used, need

to be selected carefully. One program director said that she

looked for a male counselor who

would not be too aggressive and

harshly confrontational. The

male counselor selected had the

desired low-key demeanor, but

he was unable to confront the

women with their issues. Instead,

he felt sorry for the women, took

on a role as their caretaker, and

pushed to do such activities as

taking the women to the gym.

The women’s response was to act

out in relation to this man,
becoming very needy and

dependent (for example, by

urgently requesting immediate

individual sessions).

Women are able to set responsible standards and to demand—

in a positive, nurturing way—

that other women meet these

expectations. Male staff must also

have this quality. 

The grantees point out that,

unquestionably, women clients

need to experience a positive and

supportive male role model at

some point in their recovery. The

real issue is: what is the best time

for this—during in-custody treatment, in the post-release community treatment phase, or in the

continuing care phase?

In Delaware, where women

now receive a continuum of care

at all these levels, the first tentative answer seems to be “after the

community treatment phase.” 

Their experience is that

women in the coeducational TC

work release program are still

vulnerable to their pre-prison

patterns of relationships with

abusive men. Work on developing positive male-female relationships may need to come after the

woman has set up a stable recovery process and has resolved her

issues of employment and selfsufficiency. 

Qualities of

Treatment Staff

Staff at the North Rehabilitation

Facility state the most important

quality is “the counselor must be

perceived as caring.” Other

grantees point to the staff’s attitude and their energy, commitment, integrity, and compassion

as being paramount to the healing process.

Recruiting Staff

As one project director expressed

it, what is emerging is a new type

of professional—counselors who

know both the custody environment and substance abuse treatment. This director suggests that

it is highly desirable to find counselors who have come out of the

correctional system. It is even

better if this person comes with

education or training about the

developmental theories regarding women and treatment, how

to handle paperwork, to do

assessments, and to match clients

with appropriate treatment

strategies. At this point, few

counselor candidates will have

all these qualifications. The CSAT

demonstration programs are

using a variety of strategies to

expand the number of qualified

counselors available for their programs. These include:

• Agree in advance, at the time a

counselor is hired, on a plan

for further outside training,

such as through seminars,

bachelor’s degree programs,

and workshops.

• Conduct intensive in-house

training. At the In Focus program, staff receive 40 hours a

year of trainings on such topics

as women-specific issues, parenting, co-occurring disorders,

relapse, and criminality.

• Offer internships and part-time

placements for students. The

OPTIONS TC program, for

example, is a popular student

placement choice, and both

graduate and undergraduate

students have participated in

the program. The students

receive free training, and the

project may possibly gain a

staff member later. 

• Provide part-time work for correctional officers who are starting a new career. Two projects

have been able to employ corrections officers who were

studying for a social work

degree—an ideal combination.

• Employ returning program

graduates within the program.

The Forever Free program has

graduates in stable recovery

who are both on their staff and

volunteer to come back to lead

groups. WCI Village also uses

graduates in a volunteer capacity; the graduates volunteer to

lead groups and support the

program. These volunteer

activities help WCI graduates

obtain the training and hours

needed to become a certified

substance abuse counselor.

Training and Staff

Supervision 

In-house training and ongoing

supervision of staff are very

important in a jail or prison environment. This is a difficult population, with multiple needs, and

staff may need help to avoid

becoming overinvolved emotionally and burned out. Staff who

are recovering themselves have

to be vigilant that the daily work

is not their own treatment. TCs

have been moving toward inclusion of more clinically trained

staff members, not just supervisors, in combination with experienced certified counselors. This

includes professionals who are

oriented toward traditional mental health models of treatment

Chapter 7—Critical Issues in Implementing Programs

138
(Carroll and Sobel 1986). The balance in staff backgrounds is helpful in both TC and other models.

Types of training may need to

cover such issues as:

• Understanding the TC milieu for

women. Clinical staff who have

not experienced a TC themselves need to understand how

to work in this environment,

which is so dependent on

mutual self-help and peer

responsibility. Counselors who

have experienced a male TC

themselves can have great difficulty in adjusting to the less

confrontational tone of a

woman’s program. In one of

the CSAT demonstration programs, two counselors could

not make this adjustment and

had to be replaced.

• Adopting an open, clinical mind

set. Counselors who are recovering themselves may have a

tendency to overuse the techniques that helped them (the

“comfortable and familiar ”

syndrome). The treatment

models used by the CSAT

grantees take advantage of a

wide array of therapeutic tools,

matched to the needs of the

particular woman. Training can

encourage counselors to

understand the women as

individuals, with different

needs, and to broaden their

repertoire of responses and

techniques. 

• Understanding the program’s

theory and process of change

model and how to use it in

assessing and planning each

woman’s treatment. Counselors

need both the curiosity and the

professional mind set to ask,

“What is this woman ready for

developmentally? For her,

what is the attraction of the

addiction? How does it make

her feel? What does she get out

of it?” Women hold on to addiction and its lifestyle just as

many abused women stay with

the abuser. In both cases, the

person must understand and

come to terms with the pull—

the attachment—before it can

be given up. 

Cross-Training for

Treatment and

Corrections Staff

Cross-training for program staff

is considered to be critical for the

success of a drug treatment program (Bureau of Justice

Assistance 1991, p. 49). This training educates treatment staff

about corrections issues, such as

security, and educates corrections staff about treatment issues.

The training serves a number of

vital functions, such as promoting teamwork and helping the

treatment and corrections staffs

to understand their roles and any

existing stereotypes.

Cross-training needs to be

scheduled before the program

gets underway, and then be followed up by regularly scheduled

in-service training sessions. Such

training may be complex in the

beginning, and professional

training assistance can sometimes be helpful.

Topics for Cross-Training

Table 15 lists general cross-training topics (not specific to

women’s programs) for treatment and corrections staff in

prison and jail settings.

The CSAT women’s program

grantees suggest that, in addition to these generic topics,

cross-training for the assigned

program security staff and their

substitutes needs to encompass

the following:

• Training regarding AOD treatment, including such issues as

confidentiality of program

information

• Need for sensitivity to the

emotions and potential distress

that can be evoked during

counseling

• Importance of maintaining a

positive, nonpunitive environment within the treatment program

• The critical role of support and

encouragement that correctional staff can play after treatment hours

Grantee Lessons

on Cross-Training

The Stepping Out program staff

recommends that cross-training

begin early in the startup process.

One lesson they learned was that

custody staff need succinct and

unambiguous information about

the program. Giving the custody

staff volumes of material is not

useful to them; what they need

are program summaries and

focused information on how

their duties interact with the program.

For the treatment staff during

cross-training, women’s program

grantees suggest the following

topics:

• Special issues regarding treatment within a corrections setting

• Security issues and potential

breaches

Chapter 7—Critical Issues in Implementing Programs

139
• Importance of not “triangulating” patients, treatment staff,

and correctional officers

* * * * * *

One available resource is the

cross-training curriculum for

probation/parole officers and

drug treatment personnel developed jointly by the National

Association of State Alcohol and

Drug Abuse Directors

(NASADAD) and the American

Parole and Probation Association

(APPA). Call 202-293-0090 or email: dcoffice@nasadad.org.

CSAT also has a cross-discipline

training course for corrections

and drug treatment personnel

(see Criminal Justice-Substance

Abuse Cross-Training under Staff

Training in the Resource List, this

volume).

* * * * * *

Relationships With

the Medical and

Psychiatric Staffs

Much has been written about the

inadequate medical services that

jails provide to women (Gray et

al. 1995). Lawsuits filed by or on

behalf of women in jails predominantly deal with medical services. Only about half of U.S. jails

offer gynecological and obstetrical services, about 70 percent

offer psychiatric services, and 90

percent do intake screening and

health appraisals. Among State

prisons, about 95 percent do

intake screening and health

appraisals and 80 percent provide obstetrical, gynecological,

and psychiatric services (ACA

1990). 

The CSAT demonstration

grantees stressed how important

it is to have a good relationship

with the facility’s medical and

psychiatric staffs. Based on their

experience, the women’s treatment staffs in jails pointed out

the following issues:

• Screening for sexually transmitted diseases (STDs). Women

offenders with drug problems

have a high rate of STDs, often

untreated. Programs need to

be aware that the medical

screening available for women

offenders may be so limited

that STDs are neither diagnosed nor treated. One jail

program supported by CSAT

reported that none of their

women clients were being

diagnosed with STDs during

the standard medical exams.

When an STD specialist joined

the program and began screening the women, 70 percent

were found to have one or

more STDs.

• Need for medication. A number

of women being admitted to

jails and detention centers are

in need of medication for

major mental disorders.

Women leaving mental institutions may find themselves

alone and become homeless;

they stop taking prescribed

medications and self-medicate

with street drugs that are easily accessible (Lord 1995). The

problem is self-perpetuating.

While actively using drugs, the

woman becomes noncompliant with her psychiatric treatment and medications. Women

with a dual diagnosis (a major

mental disorder combined

with substance abuse) need to

be stabilized when they enter

custody. With medication, a

number of these women will

be able to participate in a shortterm, intensive pre-release

program. 

In prison settings, the staffs

commented on the following

issues:

• Need for gynecological care.

One program director commented on the high level of

gynecological problems among

the women and their previous

lack of medical care. Some

women in this program have

HIV and STDs. Other women

are already starting menopause in their late 30s and early

40s. These are issues related to

relapse in women.

• Need for supportive prenatal

and postpartum care. At WCI

Chapter 7—Critical Issues in Implementing Programs

140

Basic addictions curriculum

Program philosophy

Treatment methodology

Inmate management style

Life/safety procedures

Disciplinary procedures

Report writing

Team building

Legal issues/inmate rights

Policy and procedures

Communication skills

Cultural diversity

From: Bureau of Justice Assistance, Design and Implementation Issues for

Drug Treatment in the Jail Setting: Monograph, 1991.

Table 15. Cross-training topics
Village, the program provides

a nurturing, supportive climate

for a woman throughout her

pregnancy and after birth of

the baby. All the program participants provide this support.

The woman delivers her baby

at the hospital, and the infant

is immediately removed either

to foster care or to a relative.

When the mother returns to

the prison infirmary after the

delivery, the whole Village

group comes to visit and support her as she grapples with

her feelings about the separation from her infant.

• Overprescription of medications. In the prison setting,

program directors felt that, for

some individuals, psychiatric

medications are being overprescribed and prolonging their

addictions.

Treatment staff needs to have

good ongoing communication

with the facility’s psychiatrists

and mental health care providers.

As was discussed in chapter 4,

most of the programs attempt to

admit women who have serious

mental health diagnoses, as long

as they are stabilized on medication and can benefit from—and

not disrupt—the program. These

women will need a mental health

consultation before entering the

treatment program, and some

may need to be transferred temporarily to the psychiatric unit

while in treatment. Issues that

have come up in this collaboration include:

• A need for information. One

program finds it difficult to get

adequate information about

individuals from the mental

health unit. For example, staff

want to know more about the

expected effects of the drugs

that each client is taking, particularly the potential side

effects.

• Need for orientation on the program. The mental health staff

needs to understand the criteria governing which women

can be accommodated by the

treatment program. One program found that, because programming is so scarce for

women offenders with severe

mental illness, the mental

health unit kept trying to send

women who were not appropriate for their program.

Evaluating the

Program

Evaluation of programs has

become increasingly important

during the 1990s, as both the

Federsl and State governments

have demanded more accountability for government funds.

State AOD agencies generally

require that programs have continuous quality improvement

(CQI) or quality assurance (QA)

programs. Because policymakers

will want to know about results,

it is important to design an evaluation while a treatment program is being developed. Even if

there is no formal budget for

evaluation, it is still possible to

design simple but useful measures for evaluating process and

outcomes. This information

needs to be collected consistently

from the time the program starts.

Research on outcomes of treatment, especially for women, is

badly needed. The CSAT-supported demonstration programs

described in this Guide have all

developed process and/or outcomes evaluation plans, so that

findings will be available on

these models. But every project

should be doing some evaluation, and the plans need to be

made in tandem with the initial

implementation planning. Baseline data may need to be collected before the program starts.

Some of the important reasons

for carrying out some type of

evaluation include:

• Obtaining financial support.

This is a time of uncertain and

changing funding streams.

Gathering feedback that

shows the success of the program, and the program’s ability to demonstrate concrete

results in reducing recidivism

and saving public money, can

be a significant asset in helping to generate continued

funding and administrative

support for the program.

• Insight for staff about what

works. Specific feedback from

participants is invaluable in

showing what is working, or

not working, in a program.

• Knowledge for matching clients

to community programs. Feedback about follow-up outcomes

can be particularly useful for

in-custody treatment programs,

since it will help determine

which community continuing

care facilities and resources are

of most benefit to which types

of clients. This information will

improve treatment matching.

Potential types of evaluation

can demonstrate:

• Advantageous effects on the

institution. Evaluation can

show that a treatment program provides concrete advantages for the prison or jail.

For example, data can show

Chapter 7—Critical Issues in Implementing Programs

141
the program’s effects in reducing disorderly behavior and

rules violations among the

participant population.

• Process information. Data can

show whether the program is

being implemented according

to plan, the number of clients

being retained and for how

long, the number of clients successfully completing the program, the range and type of

community resources introduced to the clients, the level

of client satisfaction with the

program, and the clients’ selfevaluation of change.

• Treatment outcomes. Postrelease client outcome measures can show the percentage

of program participants who

enter post-release treatment,

the types of treatment

received, and the period of

time they remain in treatment.

At 3-month follow-up after

release, outcome measures can

be used to assess client drug

use (self-report and urinalysis,

combined with psychosocial

measures), and client attendance at mutual-help support

groups.

• Recidivism outcomes. The

recidivism of clients can be

measured by: rate of recidivism for program graduates at

6 months and 12 months; rearrest status at 1 year follow-up;

and the cause of the recidivism

(for example, new arrests vs.

technical probation/parole violations).

• Other indicators of improvement. Other measures can look

at the clients’ improved social

and economic functioning,

such as employment or schooling, gaining custody of children, and living in independent

and drug-free situations. Cost

data are particularly important

in the current funding environment. How much government

money is being saved when a

substance-abusing offender,

after treatment, is able to work

and become economically selfsufficient, to resume care of her

children, and to cease criminal

activities? Such cost-offset data

are critical for convincing State

policymakers about the cost

benefits of treatment programs. 

* * * * * *

For a brief discussion of process

evaluation and its challenges in

correctional settings, see “Process

Evaluation Techniques for

Corrections-based Drug Treatment Programs” (Scarpitti et al.

1993). Other brief resources on

program evaluation will be found

in Establishing Substance Abuse

Treatment Programs in Prisons: A

Practitioner’s Handbook (CSAT

1993a, pp. 60-65) and in TIP 17,

Planning for Alcohol and Other Drug

Abuse Treatment for Adults in the

Criminal Justice System (CSAT

1995a, pp. 91-95). For a full description of the evaluation process and

the many variables that should be

addressed in well-designed studies, see TIP 14, Developing State

Outcomes Monitoring Systems for

Alcohol and Other Drug Abuse

Treatment (CSAT 1995c). 

* * * * * *

Chapter 7—Critical Issues in Implementing Programs

142
Part IV

Summaries of Programs

T

his chapter provides an

overview of the key components of nine women’s

prison and jail demonstration programs supported by the Center for

Substance Abuse Treatment

(CSAT). The materials that these

programs are prepared to share

with others are listed at the end of

each description. Contacts are

also listed, so that program

administrators and others may

request additional information

about these demonstration projects. More extensive program

summaries, histories of program

implementation, and costs and

evaluation results from most of

these grant programs are also

contained in an unpublished document (CSAT’s Criminal Justice

Program Briefs 1998). 

Prison-based

Demonstration

Projects

Choices TC Program, Pine

Bluff, Arkansas

The Choices Program, operated

by the Arkansas Department of

Community Punishment (DCP),

offers a modified therapeutic

community treatment program

with a minimum stay of 90 days

to 24 months. This institution is

designed to serve only those

offenders with nonviolent

offenses. Many are first-time

offenders—a population with a

good opportunity to change their

lives. The modified TC program,

with a capacity of 50 clients,

serves approximately 260 people

per year and is available to both

male and female residents in separate housing arrangements. To

date, 149 residents have completed the program. Random drug

testing occurs in this facility

about once every 2 to 3 weeks.

After completing the program,

most participants proceed to probation and parole.

DCP and treatment staff have

established linkages with mental

health, substance abuse, and

other health providers in the

community to assist program

participants with their transition

back to the community. Many

participants complete the treatment component before completing their sentence, and initially

these women had to be released

back into the general population

in the facility before being

released into their communities.

In spring 1996, a separate dormitory was made available so those

who have completed treatment

can remain together while finishing their sentences without

returning to the general population.

The program offers a range of

services from vocational counseling to parenting training.

Choices is unique in part because

it is the only residential treatment

occurring in a secure community

corrections setting, where the

goal is rehabilitation and treatment. The institution is designed

as an alternative to prison

because of the lack of prison bed

space.

Data from the CHOICES program show that as of July 30,

1997, 699 clients had been admitted to the program and 452 had

successfully completed it, five

had received participation certificates, 80 residents were currently

participating, and 137 clients had

been discharged. The discharged

figure includes those who could

not complete the program for

reasons outside their control.

Based on its initial success with

the TC modality, all community

punishment facilities in Arkansas

are now being converted to modified therapeutic communities.

Materials available: A short

guide on how to use and integrate a Rope Course into a treatment program.

Contact: Glenda L. Spratt,

Arkansas Department of

Community Punishment, 105

145

Chapter 8—Summaries of CSAT

Women’s Programs for Offenders
West Capitol Ave., 2 Union

National Plaza, 2nd floor, Little

Rock, Arkansas 72201, phone 501-

682-9570, fax 501-682-9534

Delores J. Baylor Women’s

Correctional Institution (WCI)

Village TC Program, Wilmington, Delaware

Roughly 42 women at a time live

and work together in this State

prison-based modified therapeutic community (TC), where the

women share a positive family

environment for 6 to 18 months.

The program combines TC therapy strategies with culturally sensitive approaches designed to

meet the needs of women. A

“women oriented” focus is used

to deal with issues of self-esteem,

sexuality/intimacy, interpersonal

skills, relationships with family

and significant others, cultural/

ethnic identity, parenting, health

issues, empowerment, job skills,

leisure time, and drug/alcohol

use. Village staff is primarily

female. Among the many techniques used are transactional

analysis, psychodrama, branch

groups, encounter and feelings

groups, and seminars.

Recently, the Village added a

new aftercare component. Prior

to their release, an aftercare coordinator works with the women to

arrange transitional care in community-based residential drug

treatment programs. This

includes preparing the women to

go before the Parole Board, transferring them from WCI Village to

the CREST Outreach Center, and

providing them with educational, vocational, mental health,

medical, and social services. Most

residents enter a coeducational

work-release TC. After this treatment phase is completed, the

Village coordinator continues to

assure that ongoing support

services and social supports are

available. 

Materials available: A program manual for participants in

English and in Spanish and curriculum outlines.

Contact: Gwen Empson,

Program Director, WCI Village,

660 Baylor Boulevard, New

Castle, Delaware 19720, phone

(302) 577-3004, ext. 1224, fax (302)

577-5861

Forever Free Program,

California Institution for

Women, Frontera, California

Forever Free provides an intensive in-prison treatment program

lasting for a minimum of 6

months, with women participating in drug treatment programming for 20 hours per week. The

women also participate in the

prison work program for an additional 20 hours. Since 1991, the

program has served 1,723 women.

Approximately 250 women enter

the program each year; the

monthly caseload is 120 women.

However, this original program

is now being expanded. In August

1997, the California legislature

decided to double the in-prison

program and to add $500,000

annually to the community aftercare component. This expanded

treatment program will now

serve 240 women per month in

prison and will place 50 percent

of program graduates into contracted community treatment.

The in-prison treatment staff will

double and the program’s annual

capacity will expand from 250 to

500 women.

In prison, 60 women will start

the intensive treatment program

every 6 weeks, entering closed

groups of 15 each. These groups

will experience all six components of the program, which are:

recovery education, relapse prevention, women’s workshops,

Reasoning and Rehabilitation,

12-Step groups, and case management. In California, prison

inmates are required to work 8

hours per day. The Forever Free

participants receive 4 hours of

work credit for the time they

spend in treatment and, in addition, work 4 hours a day. Twenty

program participants receive random drug testing each week,

with additional urine testing performed if drug use is suspected.

Over the life of the program, the

overall rate of positive urines has

been less than 2 percent among

program participants.

Under the planned expansion,

50 percent of Forever Free participants will have access to 6

months of community aftercare

through contracted treatment

slots. The expanded program

offers community aftercare

placement in any California

county, whereas the original

placement program offered

community aftercare in just four

targeted southern California

counties. Based on the availability of local county funding, it will

be possible to make additional

community referrals.

Over the program’s 6-year history, three separate outcome

evaluations have looked at program effectiveness. Results have

consistently indicated that length

of time in treatment relates to

success on parole, and that best

outcomes occur when in-prison

Chapter 8—Summaries of Programs

146
treatment is combined with 5

months or more of community

aftercare. More than 91 percent

of entering participants have

completed the in-prison program. The dropout rate has been

less than 6 percent, with 3 percent of participants removed for

logistical or judicial reasons.

Results indicate that 38 percent

of program dropouts were successful on parole compared to a

success rate of 62 percent among

program graduates, of 72 percent

among program graduates who

enter residential community

treatment, and of 90 percent success on parole among program

graduates who remain in residential aftercare for 5 months or

more. 

Contact: Angela Knox or Dick

Jeske, Forever Free Program

Coordinators, California Institution for Women, 16756 Chino

Corona Road, Frontera, California 91720, phone 909-597-1771,

ext. 6570, fax 909-597-7596.

Recovery In Focus Program,

Salem, Oregon

This 6-month pre-release day

treatment program is a modified

TC serving incarcerated women

who volunteer at Oregon

Women’s Correctional Center.

The program provides substance

abuse treatment services, as well

as family and life skills to female

inmates within 4 to 6 months of

release. Goals are to promote

treatment and recovery; prevent

recidivism, relapse, and homelessness; and to reunite women

with their children. Pregnant

women and women with children receive priority. Clients

receive group and some individual therapy aimed at enhancing

family, parenting, and life skills,

as well as providing tools for job

searches, self-esteem, and selfempowerment. Women receive

family and child visitations

supervised by a family therapist.

The transition component

includes such elements as individual release/relapse prevention

planning, transitional leaves,

work release, and an individually

matched mentor. The mentor is a

volunteer from the woman’s

home community who is assigned

before the client leaves the

Recovery In Focus Program.

Volunteers, who make a 6-month

commitment and receive training,

serve as guides and role models as

well as positive support persons

for the women.

An outcome evaluation of In

Focus clients found that those

who complete the program have

fewer subsequent arrests, fewer

acts of absconding, and are better

adjusted to community life than

clients who do not complete the

program (primarily because of

institutional transfers) or than

women offenders who need

AOD treatment in prison but do

not receive it (Finigan 1997). The

study compared 211 women: 93

who had competed the program,

62 non-completers, and a comparison group of 56 women. In

Focus was effective in referring

women into community treatment and motivating them to

complete it. Of program completers, 84 percent entered community treatment after their

release and nearly half (46 percent) completed it, compared

with 48 percent and 28 percent

respectively for the comparison

group.

During the 1-year period after

release from prison, women who

completed the In Focus program

had significantly fewer rearrests

for new crimes and fewer acts of

absconding during parole—an

act that signals not only loss of

supervision but often the return

to a criminal lifestyle. Data

showed:

• Program completers: Only 30

percent had a new subsequent arrest, with 31 total

acts of absconding per 100

participants

• Program noncompleters: 44

percent had a new subsequent arrest, with 101 total

acts of absconding per 100

non-completers

• Comparison no-treatment women:

65 percent had a new subsequent arrest, with 121 total acts

of absconding per 100 women

who needed but did not participate in the In Focus program.

In the year after release, In

Focus program completers, compared to the noncompleters and

comparison women, had entered

or participated in more community-based self-improvement

programs and had made more

efforts to gain employment, to be

involved in training, or to gain

financial stability. 

Materials available: An information packet and guidelines for

mentors in the aftercare program. Client materials include a

self-rating behavioral assessment

tool (for personal accountability),

a behavioral treatment contract,

AA/NA meetings attendance

report form, recovery worksheets, and a personal release/

relapse prevention discharge

plan form.

Chapter 8—Summaries of Programs

147
Contact: Linda Clays, Recovery

In Focus Program, 2809 State St.,

Salem, Oregon 97310, phone 503-

373-1928, fax 503-378-8370.

Jail-based

Demonstration

Projects

Sisters in Sober Treatment

and Empowered Recovery

(SISTER) TC Program, San

Francisco, California

The SISTER Program is a jailbased modified therapeutic community for women operated by

the San Francisco Sheriff’s

Department in County Jail

Number 8. The program, set in a

separate pod in the jail, has a

capacity of 56 clients; the average

length of stay is 53 days. Clients

have a presentence or sentenced

status, and the program is voluntary. About 225 clients were

served during the 1994-95 fiscal

year. 

Within this modified therapeutic community, a wide range of

clinical and ancillary services are

provided, including group and

individual counseling; acupuncture 5 days a week; parenting

programs; GED, literacy, and

writing training; HIV education

and counseling; and specific

counseling for prostitutes in a

group called “EX-SEX Workers

Group.” The program has special

groups for lesbian and bisexual

women; culturally specific

groups for African Americans,

Hispanics, and Pacific Islanders;

and AA/NA meetings in the facility in both English and Spanish.

Clients are tested for drugs if staff

suspect use.

Aftercare is an important

component of the program.

Pre-release planning includes

vocational and educational

assessment, job training, and

relapse prevention work 5 days

a week. Residential treatment is

provided in the community for

some women at Walden House,

and residential treatment for

pregnant women is provided in

the community by Jelani House.

The program is beginning new

initiatives for women unable to

access these limited community

services, including an outpatient

alumnae group that will meet in

the evenings and a SISTER support group.

A 3-year outcome evaluation of

the SISTER Program concluded

that this “in-custody jail- based

substance abuse treatment is

effective in decreasing substance

use and decreasing the involvement of women in the criminal

justice system due to substance

abuse problems” (Santiago et al.

1996). This study analyzed the

county arrest records of 146 out

of 811 participants at 1 year after

their successful discharge from

the SISTER program. To analyze

recidivism factors, the evaluation

team studied 104 women who

went through SISTER, looking at

rearrest data 1 year after the

women were discharged from

the program. The program was

most effective for AfricanAmerican women between 30

and 40 years of age who had substance abuse problems but were

not diagnosed with severe

depression. Findings included:

• Decrease in recidivism. Women

treated in the SISTER program

were rearrested 50 percent less

often than comparison group

women. In addition, there was

a longer period before rearrest

for the SISTER women than for

the comparison group.

• Decrease in violent crimes. The

SISTER women were rearrested for less severe or violent

crimes than the comparison

group women. The program

was also effective in reducing

drug-related crimes.

• Importance of post-release treatment. The SISTER participants

who were most successful were

those who went to a community residential treatment program after discharge from the

SISTER program.

The evaluators found that

women who received acupuncture and participated intensively

in treatment program activities

were less likely to be rearrested.

Materials available: A program manual. Also an introductory booklet for women entering

the SISTER Project titled “SISTER

Project ABCs,” which contains a

warm and welcoming explanation about women’s treatment

and the caring family environment the program provides, as

well as program/contract rules

and worker assignments.

Contact: Ramona Massey,

Program Director, SISTER

Project, SISTER Project/Sheriff’s

Department, 425 Seventh Street,

San Francisco, California 94103,

phone 415-522-8000, fax 415-522-

8056

Chapter 8—Summaries of Programs

148
Stepping Out TC Project, San

Diego, California

This in-custody residential treatment program for women is operated at Las Colinas Detention

Facility by the Community

Connection Resource Center.

Stepping Out is a 64-bed modified

therapeutic community for sentenced inmates who have a minimum of 50 days remaining to

serve. Women average 62 days in

treatment, but have stayed as long

as 179 days. The program is eclectic in design, incorporating elements of the TC and social model

modalities in a cognitive behavioral framework.

The women participate in educational and process groups and

receive individualized case management services. Elders in the

program assist with orientation,

housekeeping duties, and other

assignments. The program’s own

registered nurse provides comprehensive medical screening,

tests for STDs and other communicable diseases, and health education. Two deputies are assigned

to the program, who assist with

screening and movement of the

inmates. Recommended levels of

treatment following release are

assessed by the Adult Substance

Abuse Survey (ASUS) and the

Level of Supervision Inventory

(LSI), combining substance abuse

severity and criminogenic factors. These instruments serve as a

guide for treatment planning.

Aftercare case managers facilitate

transition into the community,

driving participants from the jail

at release to their appointed destinations. The Stepping Out

Project uses bilingual program

materials.

Stepping Out operates an

aftercare component which provides intensive outpatient treatment services and sober living.

Up to six Stepping Out participants can live in the program’s

own women’s sober living house,

or be placed in other sober living

environments paid for by the

program for the first 30 days. The

program provides a holistic continuum of care facilitated by

Community Connection’s extensive service network for offenders in San Diego County.

Additional services for Stepping

Out clients include job development and placement assistance,

referrals to supportive services,

clean and sober recreation, and

“Freedom 1st,” the agency’s

mutual-help group created by

and for ex-offenders.

An outcome evaluation was

conducted for 174 women

inmates who participated in the

Stepping Out program between

August 15, 1994 and August 15,

1995 (Paredes 1997). The study

used criminal justice followup

data for 1 year after participants’

release. Outcomes were compared with those for a comparison group of 52 inmates who met

the same basic criteria as

Stepping Out participants, but

who had not received AOD treatment in jail.

The evaluation showed a

marked improvement in the

arrest rates of women participants in months 4 through 12 of

the followup period. The

Stepping Out participants who

had continued into community

aftercare after their release were

significantly less likely to be

arrested and, if arrested, were

less likely to be found guilty and

convicted of their alleged crimes.

The provision of clean and sober

housing for the first month and a

half of aftercare significantly

increased a woman’s total time in

treatment. Women who were

provided only with aftercare

treatment stayed in treatment for

an average of 33 days. Women

provided with both aftercare

treatment and safe and sober

housing stayed in treatment for

80 days, more than double the

time for those in aftercare alone.

Contact: Anita Paredes,

Deputy Director, Community

Connection Resource Center,

4080 Centre Street, San Diego,

California 92103, phone 619-291-

4790; fax 619-291-4704

OPTIONS TC Program, Philadelphia, Pennsylvania (a familyoriented program affiliated

with CSAT’s Target Cities grant

program)

More than 8 of every 10 women

offenders in the Philadelphia

county jail system are chemically

dependent. Since October 1992,

more than 1,500 offenders have

received intensive treatment in

this nontraditional, 70-bed TC

specifically designed for women.

This TC employs a communal,

noncompetitive approach instead

of a more traditional hierarchical

TC structure. The Center encourages clients to share leadership

and responsibility in nonauthoritarian and nonabusive ways.

Program committees give participants a chance to exercise leadership and practice cooperation.

Clients are referred to the

Center by the courts, by social

workers or other staff, and

through self-referral. Each potential client is assessed for chemical

Chapter 8—Summaries of Programs

149
use/misuse/abuse, psychiatric

problems, and the woman’s ability to handle the intense TC experience. Women enter the program at any time through a

Newcomers group. This group

allows staff to assess each new

client’s needs and adjustment

problems and to determine suitable placement. 

The program’s treatment structure—a series of 8-week cycles—

is designed to fit the rapid

turnover in a county prison population. Cycles are built around

recovery and other issues,

although some concerns remain

constant (e.g., abuse, self-image,

parenting, and codependency).

Clients can enter at any stage in

any cycle. Group therapy is the

principal mode of treatment,

supported by individual counseling and 12-Step meetings. Clients

eligible for an early release program may also receive family

therapy. An innovative video

therapy project is used to

enhance self disclosure, family

reunification, and relapse management skills.

During incarceration, clients

receive a wide array of services

from other components of the

Philadelphia Prisons System. An

outreach coordinator provides

for community resources, including education and services. In

addition, a multi-agency, early

parole project called Forensic

Intensive Recovery provides

access to community treatment

slots for female offenders with

substance abuse problems.

Materials available: Program

contract and rules, cycle materials, information related to the

special video project, and smokecessation materials.

Contact: Deborah Raddock,

Director, OPTIONS Program,

Philadelphia Industrial Correctional Center, 8301 State Road,

Philadelphia, Pennsylvania 19136,

phone 215-685-7111; fax 215-685-

7199 

Incarcerated Women’s Recovery

Program, Seattle, Washington

This short-term, intensive program for women is housed in the

North Rehabilitation Facility, a

Seattle detention center. Average

length of stay in the program is

14 to 17 days, although the model

is designed for stays of 90 days or

more. In 1995 approximately

1,000 women were admitted to

the facility, and about 400 were

involved in the Women’s

Recovery Program. Up to 39

women can be provided substance abuse services at one time.

The primary treatment modality within the institution is “outpatient care,” with a focus on

reducing recidivism. There is a

special treatment group for

chronic recidivists. Readiness for

treatment is a major issue.

Services include group counseling for substance abuse, chemical

dependency education, relapse

prevention, 12 step groups, anger

management, an STD outreach

project (including testing and onsite treatment), family counseling, adult basic education, GED

testing and preparation for testing, general medical health services, acupuncture, mental health

counseling, and housing placement assistance. Clients are tested for drugs if staff suspect use.

The program uses a 5-day

“triage” process to assess clients.

On day 1, clients fill out a twopage triage form. If necessary, a

multi-page assessment is conducted in one or more topic

areas. A four-person triage

team—made up of three chemical dependency counselors and

an employment development

specialist—meets every day,

reviewing all new admissions.

The team looks for chemical

dependency and vocational, educational, and mental health

issues, among others. On day 2,

the client receives a case manager

and recommendations for programs and on days 3 and 4, she

receives a detailed program briefing. A client begins classes on the

fifth or sixth day.

The program has designed

transition services that minimize

service interruption. The case

management strategy is to link

the client to a community-based

substance abuse provider.

Residential treatment is provided

at one facility and outpatient

treatment at three locations. The

program pays for some of these

placements. In addition, two

mental health counselors and a

housing counselor begin working with the clients while they

are in the institution, and continue to work with them while they

are in the community.

Materials available: Cognitivebased women’s program curriculum based on stages of change

and mastery of skills; participant

materials for a group concerning

“boosters” (chronic shoplifters).

Contact: Lucia Meijer, North

Rehabilitation Facility, 2002 N.E.

150th St., Building No. 23, Seattle,

Washington 98155, phone 206-

296-6826, fax 206-296-7585

Chapter 8—Summaries of Programs

150
Women’s Acupuncture and

Awareness Center, Baltimore,

Maryland 

This short-term, 2-week intensive intervention program targets female substance abusers

who are awaiting trial in the

Baltimore City Detention Center

(BCDC), primarily for drugrelated offenses. Inmates selected for the program are those

with less extensive histories of

drug use and crime, who are

likely to be released back to the

streets at the time of trial.

Whenever possible, the

women live in a single dormitory while they participate in the

program, which combines structured individual and group

rehabilitation services with

acupuncture treatment 5 days

per week. The program uses a

short-term educational, skillsbuilding, and motivational

model, with special emphasis

on enrolling women in community substance abuse services

after their release. Twelve

women participate in each

cycle, and currently, 90 percent

of participants graduate. More

than 600 women graduated

from the program between

August 1993 and August 1995.

The daily psychosocial sessions

address not only drug dependency, but related issues that the

women must resolve if they are

to achieve long-term improvement. Educational groups focus

on such relapse prevention skills

as anger management, assertive

communication, drug refusal

skills, and daily planning. In

addition, clients participate daily

in a 1-hour group therapy session

to process women’s issues and

concerns related to recovery.

Finally, each client participates in

a minimum of five individual

counseling/case management

sessions for treatment and aftercare planning with her assigned

master’s-level therapist.

Women who remain incarcerated at the Detention Center after

this intensive treatment receive

aftercare. This aftercare includes a

weekly acupuncture group and

twice-weekly psychosocial groups

that focus on motivating the

women to enter post-release treatment in the community. When

released, many graduates receive

supportive services and sentencing inducements, with most aftercare provided by the Johns

Hopkins Hospital Comprehensive Women’s Center. Clients initially participate in an intensive

day treatment program and graduate to less intensive care based

on attendance, evidence of drug

abstinence, and progress on critical goals of their individual treatment plans.

Contact: Mary E. McCaul,

Ph.D., Comprehensive Women’s

Center, 911 N. Broadway,

Baltimore, Maryland 21205,

phone 410-955-5439, fax 410-955-

4769.

Chapter 8—Summaries of Programs

151

Abram, K.M., and Teplin, L.A.

Co-occurring disorders among

mentally ill jail detainees:

Implications for public policy.

American Psychology 46:1036-

1045, 1991.

American Correctional Association. The Female Offender: What

Does the Future Hold? Arlington,

VA: Kirby Lithographic Co.,

Inc., 1990.

American Public Welfare

Association. APWA’s 1994 survey of foster care maintenance

rates. W-Memo 7(7):36, 1995.

Andrews, D.A., and Kiesling, J.

Program structure and effective correctional practices: A

summary of CaVIC research.

In: Ross, R., and Gendreau, P.,

eds. Effective Correctional Treatment. Toronto: Butterworth

Press, 1980.

Anglin, M.D., and Hser, Y.

Addicted women and crime.

Criminology 25:359-397, 1987.

Anglin, M.D., and Hser, Y.

Treatment of drug abuse. In:

Tonry, M., and Wilson, J.Q.,

eds. Drugs and Crime. Chicago:

University of Chicago Press,

1990.

Austin, J.; Bloom, B.; and

Donahue, T. Female Offenders in

the Community: An Analysis of

Innovative Strategies and

Programs. Washington, DC:

National Institute of Corrections, 1992.

Bair, M.H. Special population

challenge: Preserving positive

outcomes for women clients.

TIE Communiqué. Monitoring

Treatment Outcomes and

Managed Care: Promise and

Challenge for the AOD Field, Fall

1998. 

Beattie, M. Beyond Codependency

and Getting Better All the Time.

San Francisco: Harper & Row

Publishers, 1989.

Beattie, M. Codependents’ Guide to

the Twelve Steps. New York:

Prentice Hall Press, 1990.

Beckman, L.J., and Amaro, H.

Patterns of women’s use of

alcohol treatment agencies. In:

Wilsnack, S.C., and Beckman,

L.J., eds. Alcohol Problems in

Women. New York: Guilford

Press, 1984.

Bepko, C. The Responsibility Trap.

New York: The Free Press,

1985, pp. 198-232.

Bepko, C., ed. Feminism and

Addiction. New York: The

Haworth Press, 1991.

Berenson, D. Powerlessness—

liberation or enslaving? Responding to the feminist critique of the Twelve Steps. In:

Bepko, C., ed. Feminism and

Addiction. New York: Haworth

Press, 1991.

Berkowitz, G.; Brindis, C.;

Clayson, Z.; and Peterson, S.

Options for recovery: Promoting success among women

mandated to treatment. Journal

of Psychoactive Drugs 28(1):31-

38, 1996.

Bloom, B.; Leonard, E.; and

Owen, B. Profiling the Needs of

California’s Female Prisoners: An

Overview of Prison Programs.

Paper presented at the

American Society of Criminology Annual Meeting,

Miami, Florida, November 9-

12, 1994.

Bloom, B.; Lind, M.C.; and

Owen, B. Women in California

Prisons: Hidden Victims of the

War on Drugs. San Francisco:

Center on Juvenile and

Criminal Justice, 1994.

Bloom, B., and Steinhart, D. Why

Punish the Children? A Reappraisal of the Children of Incarcerated Mothers in America. San

Francisco: National Council

on Crime and Delinquency,

1993.

153

References 
Blume, S.B. Chemical dependency in women: Important issues.

American Journal of Drug and

Alcohol Abuse 16(3,4):297-307,

1990.

Blume, S.B. Alcohol and other

drug problems in women. In:

Lowinson, P.R., and Millman,

R.B., eds. Substance Abuse: A

Comprehensive Textbook. 2d edition. Baltimore, MD: Williams

and Wilkins, 1992. 

Brennan, Tim. Institutional classification of females: Problems

and some proposals for reform.

In: Zaplin, R.T., ed. Female

Offenders: Critical Perspectives

and Effective Interventions.

Gaithersburg, MD: Aspen

Publishers, Inc., 1998.

Brown, V.B.; Sanchez, S.;

Zweben, J.E.; and Aly, T.

Challenges in moving from a

traditional therapeutic community to a women and children’s TC model. Journal of

Psychoactive Drugs 28(1):39-46,

1996.

Bureau of Justice Assistance.

Design and Implementation

Issues for Drug Treatment in the

Jail Setting: Monograph. U.S.

Department of Justice, Office

of Justice Programs, 1991.

Bureau of Justice Statistics (BJS).

Women in Jail in 1989.

Washington, DC: U.S. Department of Justice, 1992.

Bureau of Justice Statistics (BJS).

Special Report: Women in Prison.

Washington, DC: U.S. Department of Justice, 1994.

Bureau of Justice Statistics (BJS).

Correctional Populations in the

United States, 1993, by Snell, T.L.

(NCJ 156241). Washington, DC:

U.S. Department of Justice,

1995a.

Bureau of Justice Statistics (BJS).

State and Federal prisons

report record growth during

last 12 months. Press release,

December 3, 1995b.

Bureau of Justice Statistics (BJS).

Bulletin: Prison and Jail Inmates

at Midyear 1997, by Gilliard ,

D.K., and Beck, A.J. (NCJ

167247). Washington, DC: U.S.

Department of Justice, 1998a.

Bureau of Justice Statistics (BJS).

Special Report: Profile of Jail

Inmates 1996, by Harlow, C.W.

(NCJ 164620). Washington, DC:

U.S. Department of Justice,

1998b. 

Bush, D.; Hecht, F.R.; La Barbera,

M.J.; and Peters, R.H. Design

and Implementation Issues for

Drug Treatment in the Jail

Setting. Washington, DC:

Bureau of Justice Assistance, in

press.

California Department of Corrections (DOC), Office of Substance

Abuse Programs. An Evaluation

of Program Effectiveness for the

Forever Free Substance Abuse

Program at the California Institute

for Women, Frontera, California:

Report to the California Legislature.

Sacramento, CA, 1993.

Camp, G.M., and Camp, C.G.

Preventing and Solving Problems

Involved in Operating Therapeutic

Communities in a Prison Setting.

South Salem, NY: Criminal

Justice Institute, 1990.

Carroll, J.F.X., and Sobel, B.S.

Integrating mental health personnel and practices into a

therapeutic community. In: De

Leon, G., and Ziegenfuss, J.T.,

eds. Therapeutic Communities for

Addictions: Readings in Theory,

Research, and Practice. Springfield, IL: Charles C. Thomas,

1986.

Center on Addiction and Substance Abuse (CASA). Substance

Abuse and the American Woman.

New York: National Center on

Addiction and Substance

Abuse at Columbia University,

1996.

Center for Substance Abuse

Treatment (CSAT). Establishing

Substance Abuse Treatment Programs in Prisons: A Practitioner’s

Handbook, edited by Wexler,

H.K. Rockville, MD: Substance

Abuse and Mental Health

Services Administration, 1993a.

Center for Substance Abuse

Treatment (CSAT). Pregnant,

Substance-Using Women. Treatment Improvement Protocol

(TIP) Series, No. 2. DHHS Pub.

No. (SMA) 93-1998. Rockville,

MD: Substance Abuse and

Mental Health Services

Administration, 1993b.

Center for Substance Abuse

Treatment (CSAT). Relapse

Prevention and the SubstanceAbusing Criminal Offender: An

Executive Briefing, by Gorski,

T.T.; Kelley, J.M.; Havens, L.;

and Peters, R.H. Technical

Assistance Publication Series,

No. 8. Criminal Justice

Subseries, Vol. I. DHHS Pub.

No. (SMA) 95-3071. Rockville,

MD: Substance Abuse and

Mental Health Services

Administration, 1993c.

References

154
Center for Substance Abuse

Treatment (CSAT). Screening and

Assessment for Alcohol and Other

Drug Abuse Among Adults in the

Criminal Justice System. Treatment Improvement Protocol

(TIP) Series, No. 7. DHHS Pub.

No. (SMA) 94-2076. Rockville,

MD: Substance Abuse and

Mental Health Services Administration, 1994a.

Center for Substance Abuse

Treatment (CSAT). Combining

Substance Abuse Treatment With

Intermediate Sanctions for Adults

in the Criminal Justice System.

Treatment Improvement

Protocol (TIP) Series, No. 12.

DHHS Pub No. (SMA) 94-3004.

Rockville, MD: Substance

Abuse and Mental Health

Services Administration, 1994b.

Center for Substance Abuse

Treatment (CSAT). Practical

Approaches in the Treatment of

Women Who Abuse Alcohol and

Other Drugs. Rockville, MD:

Department of Health and

Human Services, Public Health

Service, 1994c.

Center for Substance Abuse

Treatment (CSAT). Planning for

Alcohol and Other Drug Abuse

Treatment for Adults in the

Criminal Justice System. Treatment Improvement Protocol

(TIP) Series, No. 17. DHHS Pub.

No. (SMA) 95-3039. Rockville,

MD: Substance Abuse and

Mental Health Services Administration, 1995a.

Center for Substance Abuse

Treatment (CSAT). Producing

Results....a report to the Nation.

Rockville, MD: Substance

Abuse and Mental Health

Services Administration, 1995b.

Center for Substance Abuse

Treatment (CSAT). Developing

State Outcomes Monitoring

Systems for Alcohol and Other

Drug Abuse Treatment. Treatment Improvement Protocol

(TIP) Series, No. 14. DHHS

Pub. No. (SMA) 95-3031.

Rockville, MD: Substance

Abuse and Mental Health

Services Administration, 1995c.

Center for Substance Abuse

Treatment (CSAT). Critical

Elements in Developing Effective

Jail-Based Drug Treatment

Programming. Rockville, MD:

Substance Abuse and Mental

Health Services Administration,

1996a. (Available from the

National Clearinghouse for

Alcohol and Drug Information,

Pub. No. PHD 729.)

Center for Substance Abuse

Treatment (CSAT). Treatment

Drug Courts: Integrating Substance Abuse Treatment with Legal

Case Processing. Treatment

Improvement Protocol (TIP)

Series, No. 23. DHHS Pub. No.

(SMA) 96-3113. Rockville, MD:

Substance Abuse and Mental

Health Services Administration,

1996b.

Center for Substance Abuse

Treatment (CSAT). National

Treatment Improvement Evaluation Study (NTIES), 1997a.

[Information packet available

from the National Clearinghouse for Alcohol and Drug

Information, Rockville, MD.]

Center for Substance Abuse

Treatment (CSAT). Substance

Abuse Treatment and Domestic

Violence. Treatment Improvement Protocol (TIP) Series, No.

25. DHHS Pub. No. (SMA) 97-

3163. Rockville, MD: Substance

Abuse and Mental Health

Services Administration, 1997b. 

Center for Substance Abuse

Treatment (CSAT). Criminal

Justice Program Briefs, Demonstration Programs Supported by

CSAT: Prison and Jail Drug

Treatment Programs. Rockville,

MD: Substance Abuse and

Mental Health Services

Administration, 1998. [Available from Criminal Justice

Group, Attention Nancy

Ferguson, 8630 Fenton Street,

12th Floor, Rockville, MD

20910-3803]

Centers for Disease Control and

Prevention (CDC). Zidovudine

for the prevention of HIV

transmission from mother to

infant. Morbidity and Mortality

Weekly Report 43(16):285-287,

1994.

Chesney-Lind, M. The Female

Offender: Girls, Women, and

Crime. Thousand Oaks, CA:

Sage Publications, 1997.

Children’s Defense Fund. AFDC

maximum monthly benefit for a

three-person family, 1970 and

1994. In: The State of America’s

Children Yearbook 1995. Washington, DC: Children’s Defense

Fund, 1995.

Coley, S.M., and Beckett, J.O.

Black battered women: A

review of the empirical literature. Journal of Counseling and

Development 66:266-270, 1988.

Comas-Díaz, L., and Greene, B.,

eds. Women of Color: Integrating

Ethnic and Gender Identities in

Psychotherapy. New York: The

Guilford Press, 1994.

References

155
Covington, S.S. Awakening Your

Sexuality: A Guide for Recovering

Women and Their Partners. San

Francisco: Harper, 1991a.

Covington, S.S. Sororities of helping and healing: Women and

mutual help groups. In: Roth,

P., ed. Alcohol and Drugs Are

Women’s Issues. New York: The

Scarecrow Press, Inc., 1991b. 

Covington, S.S. A Woman’s Way

Through the 12-Steps. Center

City, MN: Hazelden, 1994.

Covington, S.S. Women in

prison: Approaches in the

treatment of our most invisible

population. Women in Therapy

21(1), 1999. In press.

Covington, S.S., and Beckett, L.

Leaving the Enchanted Forest: The

Path From Relationship Addiction

to Intimacy. San Francisco:

Harper, 1988.

Covington, S.S., and Surrey, J.L.

The relational model of

women’s psychological development: Implications for substance abuse. In: Wilsnack, S.,

and Wilsnack, R., eds. Gender

and Alcohol: Individual and Social

Perspectives. New Brunswick,

NJ: Rutgers Center of Alcohol

Studies, 1997.

Dahlgren L., and Willander, A.

Are special treatment facilities

for female alcoholics needed?

A controlled 2-year follow-up

study from a specialized

female unit (EWA) versus a

mixed male/female treatment

facility. Alcoholism: Clinical and

Experimental Research 13(4):499-

504, 1989.

Daley, B., and Przybycin, C.

Cocaine-dependent women

have unique treatment needs.

Addiction Letter 5(10):1989.

De Leon, G. Program-based evaluation research in therapeutic

communities. In: Tims, F.M.,

and Ludford, J.P., eds. Drug

Abuse Treatment Evaluation:

Strategies, Progress, and Prospects.

National Institute on Drug

Abuse (NIDA) Monograph

Series. Rockville, MD: NIDA,

1984. 

De Leon, G. Legal pressure in therapeutic communities. Journal of

Drug Issues 18:625-640, 1988.

De Leon, G. Treatment strategies.

In: Inciardi, J.A., ed. Handbook of

Drug Control in the United States.

Westport, CT: Greenwood,

1990.

De Leon, G., and Ziegenfuss, J.T.,

eds. Therapeutic Communities for

Addictions: Readings in Theory,

Research, and Practice.

Springfield, IL: Charles C.

Thomas, 1986.

Department of Corrections, State

of California. Population

Reports. Internet: State of

California, December 3, 1998.

[http://www.cdc.state.ca.us/

reports/monthpop.htm]

DiClemente, C.C., and Hughes,

S.O. Stages of change profiles

in outpatient alcoholism treatment. Journal of Substance Abuse

2:217-235, 1990.

Edlin, B.R.; Irwin, K.L.; Faruque,

S.; McCoy, C.B.; Word, C.;

Serrano, Y.; Inciardi, J.A.;

Bowser, B.P.; Schilling, R.F.;

Holmberg, S.D.; and the

Multicenter Crack Cocaine and

HIV Infection Study Team.

Intersecting epidemics: Crack

cocaine use and HIV infection

among inner-city young

adults. New England Journal of

Medicine 331:1422-1427, 1994.

Falkin, G.; Wellisch, J.;

Prendergast, M.; Kilian, T.;

Hawke, J.; Natarajan, M.;

Kowalewski, M.; and Owen, B.

“Drug Treatment for Women

Offenders: A Systems Perspective.” Project report, National

Institute of Justice (Grant 92-IJCX-K018), 1994. [Available

from Gregory Falkin, National

Development and Research

Institutes, 11 Beach Street,

New York, NY 10013]

Falkin, G.P.; Wexler, H.K.; and

Lipton, D.S. “Establishing

Drug Treatment Programs in

Prisons.” Draft. Narcotic and

Drug Research, Inc., New York,

1990.

Finigan, M. Societal outcomes and

cost savings of drug and alcohol

treatment in the State of Oregon.

Prepared for the Office of

Alcohol and Drug Abuse

Programs, Oregon Department

of Human Resources and

Governor’s Council on Alcohol

and Drug Abuse Programs,

February 1996.

Finigan, M. Evaluation of Three

Oregon Pre-Release Day Treatment

Substance Abuse Programs for

Inmates. Prepared for Center for

Substance Abuse Treatment

Technical Assistance Workshop,

January 23, 1997.

Fogel, C.I. Hard time: The stressful nature of incarceration for

women. Issues in Mental Health

Nursing 14(4):367-377, 1993.

Forney, M.A.; Inciardi, J.A.; and

Lockwood, D. Exchanging sex

References

156
for crack-cocaine: A comparison of women from rural and

urban communities. Journal of

Community Health 17(2):73-85,

1992.

Fullilove, M., and Inciardi, J.A.

Meeting the challenge of

emerging epidemics: Issues in

the crack cocaine epidemic.

Current Issues in Public Health

1:257-262, 1995.

Gendreau, P., and Ross, R.

Correctional treatment: Some

recommendations for successful intervention. Juvenile and

Family Court Journal 22:31-40,

1984.

Glick, R.M., and Neto, V.V.

National study of women’s

correctional programs. In:

Price, B.R., and Sokoloff, N.J.,

eds. The Criminal Justice System

and Women. New York: Clark

Boardman, 1982.

Gonzalez, F. Profile of the Female

Offender: A Statistical Analysis.

Trenton, NJ: New Jersey

Department of Corrections,

Bureau of Community and

Correctional Services, January

1996.

Gorski, T.T. Recovery: A developmental model. Addiction and

Recovery 11:10-14, 1991.

Gorski, T.T., and Miller, M.

Counseling for Relapse

Prevention. Independence, MO:

Independence Press, 1985.

Gorski, T.T., and Miller, M. The

Staying Sober Educational

Modules. Independence, MO:

Independence Press, 1988.

Gray, T.; Mays, G.L.; and Stohr,

M.K. Inmate needs and programming in exclusively

women’s jails, The Prison

Journal 75(2):186-202, 1995.

Harvey, E.M.; Rawson, R.A.; and

Obert, J.L. History of sexual

assault and the treatment of

substance abuse disorders.

Journal of Psychoactive Drugs

26(4):361-367, 1994.

Health Insurance Association of

America. Cost of maternity

care, physicians’ fees, and hospital charges, by census

regions, based on Consumer

Price Index, 1991. In: The

Sourcebook of Health Insurance

Data—1993. Washington, DC:

Health Insurance Association

of America, 1994.

Herman, J. Trauma and Recovery.

New York: Basic Books, 1992.

Hooker, T., and Bryant, L.

HIV/AIDS Facts to Consider.

Washington, DC: National

Conference of State Legislators, 1993.

Hooper, R.M.; Lockwood, D.; and

Inciardi, J.A. Treatment techniques in corrections-based

therapeutic communities, The

Prison Journal 73(3/4):290-306,

1993.

Hubbard, R.L.; Collins, J.J.;

Rachal, J.V.; and Cavanaugh,

E.R. The criminal justice client

in drug abuse treatment. In:

Leukefeld, C., and Tims, F.,

eds. Compulsory Treatment of

Drug Abuse: Research and

Clinical Practice. National

Institute on Drug Abuse

Research Monograph Series,

No. 86. Washington, DC: U.S.

Government Printing Office,

1988.

Hubbard, R.L.; Craddock, S.G.;

Flynn, P.M.; Anderson, J.; and

Etheridge, R.M. Overview of

1-year follow-up outcomes in

the Drug Abuse Treatment

Outcome Study (DATOS).

Psychology of Addictive Behaviors

11(4):261- 278, 1997.

Hubbard, R.L.; Marsden, M.E.;

Rachel, J.V.; Harwood, H.J.;

Cavanaugh, E.R.; and Ginzburg,

H.M. Drug Abuse Treatment: A

National Study of Effectiveness.

Chapel Hill: University of North

Carolina Press, 1989.

Hudik, T.L. Assessment of the

Substance Abuse Treatment Needs

of the Inmates of Iowa’s Correctional Institutions. Des Moines,

IA: Iowa Criminal and Juvenile

Justice Planning Agency, 1994.

Illinois Criminal Justice State Plan

Working Group. Managing

Substance Abuse in Corrections: A

Comprehensive Plan for Treatment

of Illinois Inmates, January 23,

1995.

Inciardi, J.A. The therapeutic

community: An effective

model for corrections-based

drug abuse treatment. In:

Haas, K.C., and Alpert, G.P.,

eds.. The Dilemmas of Punishment. Prospect Heights, IL:

Waveland Press, 1995.

Inciardi, J.A. Prison therapeutic

communities. In: Inciardi, J.A.,

ed. Examining the Justice Process.

New York: Harcourt Brace,

1996.

Inciardi, J.A.; Isenberg, H.;

Lockwood, D.; Martin, S.S.;

and Scarpitti, F.R. Assertive

community treatment with a

parolee population: An extension of case management. In:

References

157
Ashery, R.S., ed. Progress and

Issues in Case Management.

Rockville, MD: National

Institute on Drug Abuse, 1992.

Inciardi, J.A.; Lockwood, D.; and

Martin, S.S. Therapeutic communities in corrections and

work release: Some clinical and

policy considerations. In: Tims,

F.M.; De Leon, G.; and

Jainchill, N., eds. Therapeutic

Community: Advances in

Research and Application.

National Institute on Drug

Abuse Research Monograph,

No. 144. Rockville, MD:

National Institute on Drug

Abuse, 1994.

Inciardi, J.A.; Lockwood, D.; and

Pottieger, A.E. Crack-dependent women and sexuality:

Implications for STD acquisition and transmission. Addiction

and Recovery July/August: 25-28,

1991.

Inciardi, J.A.; Lockwood, D.; and

Quinlan, J.A. Drug use in

prison: Patterns, processes,

and implications for treatment.

Journal of Drug Issues 23(1):119-

129, 1993a.

Inciardi, J.A., and Scarpitti, F.R.

“Therapeutic Communities in

Corrections: An Overview.”

Presentation at the Annual

Meeting of the Academy of

Criminal Justice Sciences,

Pittsburgh, Pennsylvania,

March 10-14, 1992.

Inciardi, J.A.; Scarpitti, F.R.; and

Lockwood, D. “Crest Outreach

Center: Combining Therapeutic Community Treatment

With Work Release.” Presentation at the 45th annual meeting of the American Society of

Criminology, Phoenix, Arizona,

October 1993b.

Johnston, D. Child custody issues

of women prisoners: A preliminary report from the CHICAS

project, The Prison Journal

75(2):222-239, 1995.

Jordan, B.K.; Schlenger, W.E.;

Fairbank, J.A.; and Caddell,

J.M. Prevalence of psychiatric

disorders among incarcerated

women; II. Convicted felons

entering prison. Archives of

General Psychiatry 53:513-519,

1996.

Kandall, S.R. Substance and

Shadow: Women and Addiction in

the United States. Cambridge,

MA: Harvard University Press,

1996.

Kanuha, V. Women of color in

battering relationships. In:

Comas-Díaz, L., and Greene, B.

eds. Women of Color: Integrating

Ethnic and Gender Identities in

Psychotherapy. New York: The

Guilford Press, 1994.

Kasl, C. Many Roads, One Journey.

New York: Harper Collins,

1992.

Laken, M.P., and Hutchins, E.

Building and Sustaining Systems

of Care for Substance-Using

Pregnant Women and Their

Infants: Lessons Learned.

Arlington, VA: National Center

for Education in Maternal and

Child Health, 1995.

Leukefeld, C.G., and Tims, F.M.,

eds. Compulsory Treatment for

Drug Abuse: Clinical Practice and

Research. National Institute on

Drug Abuse Research Monograph Series, No. 86. Washington, DC: National Institute

on Drug Abuse, 1988.

Leukefeld, C.G., and Tims, F.M.

Compulsory treatment for

drug abuse. International

Journal of the Addictions

25(6):621-640, 1990.

Leukefeld, C.G., and Tims, F.M.,

eds. Drug Abuse Treatment in

Prisons and Jails. National

Institute on Drug Abuse

Research Monograph Series,

No. 118. Washington, DC:

National Institute on Drug

Abuse, 1992.

Lipton, D.S. “The Effectiveness of

Treatment for Drug Abusers

Under Criminal Justice

Supervision.” Presentation at

the 1995 National Institute of

Justice/Bureau of Justice

Assistance/Office of Juvenile

Justice and Delinquency

Prevention conference on

criminal justice research and

evaluation. Washington, DC:

National Institute of Justice

(NCJ 157642), 1995.

Lipton, D.S.; Falkin, G.P.; and

Wexler, H.K. Correctional drug

abuse treatment in the United

States: An overview. In:

Leukefeld, C.G., and Tims,

F.M., eds. Drug Abuse Treatment

in Prisons and Jails. National

Institute on Drug Abuse

Research Monograph, No. 118.

Rockville, MD: National

Institute on Drug Abuse, 1992.

Lockwood, D. Modeling a Modified

TC Design for Work Release.

Presentation at the annual

meeting of the Academy of

Criminal Justice Sciences,

Pittsburgh, Pennsylvania,

March, 1992.

References

158
Lockwood, D., and Inciardi, J.A.

CREST Outreach Center: A

work release iteration of the

TC model. In: Inciardi, J.A.;

Tims, F.M.; and Fletcher, B.W.,

eds. Innovative Approaches in the

Treatment of Drug Abuse:

Program Models and Strategies.

Westport, CT: Greenwood

Press, 1993.

Lord, E. A prison superintendent’s perspective on women

in prison. The Prison Journal

75(2):257-269, 1995.

Magura, S.; Rosenblum, A.; and

Joseph, H. Evaluation of in-jail

methadone maintenance: Preliminary results. In: Leukefeld,

C., and Tims, F., eds. Drug

Abuse Treatment in Prisons and

Jails. National Institute on

Drug Abuse Research Monograph Series, No. 118. Washington, DC: National Institute

on Drug Abuse, 1992.

Martin, S.S., and Scarpitti, F.R. An

intensive case management

approach for paroled IV drug

users. Journal of Drug Issues

23(1):43-59, 1993.

Martin, S.S.; Inciardi, J.A.;

Scarpitti, F.R.; and Nielsen, A.L.

Case management for drug

involved parolees: A hard ACT

to follow. In: Inciardi, J.A., ed.

The Effectiveness of Innovative

Strategies in the Treatment of

Drug Abuse. Westport, CT:

Greenwood Press, 1995.

Mattson, M.E., series editor.

Cognitive-Behavioral Coping

Skills Therapy Manual. Project

MATCH Monograph Series.

Vol. 3. Rockville, MD: National

Institute on Alcohol Abuse and

Alcoholism, reprinted 1995.

Mauer, M., and Huling, T. Young

Black Americans and the Criminal

Justice System: Five Years Later.

Washington, DC: The

Sentencing Project, October

1995.

Miller, B.A.; Downs, W.R.; and

Gondoli, D.M. Spousal violence among alcoholic women

as compared to a random

household sample of women.

Journal of Studies on Alcohol

50(6):533-540, 1989.

Miller, D. Are we keeping up

with Oprah? A treatment and

training model for addictions

and interpersonal violence. In:

Bepko, C. ed. Feminism and

Addiction. New York: Haworth

Press, 1991.

Miller, J.B. Toward a New

Psychology of Women. Boston:

Beacon Press, 1986.

Miller, J.B. Women and Power.

Work in Progress, No. 82-01.

Wellesley, MA: Stone Center

Working Paper Series, 1982.

Miller, M. Perceptions of Available

and Needed Programs by Female

Offenders in Delaware. Wilmington, DE: Delaware Council on

Crime and Justice, 1990.

Miller, W.R., and Hester, R.K., eds.

Treating Addictive Behaviors:

Processes of Change. New York,

Plenum Press, 1986.

Miller, W.R., and Rollnick, S.

Motivational Interviewing:

Preparing People To Change

Addictive Behaviors. New York:

Guilford Press, 1991.

Miller, W.R.; Zweben, A.;

DiClemente, C.C.; and

Rychtarik, R.G. Motivational

Enhancement Therapy Manual.

Project MATCH Monograph

Series, Vol. 2. Rockville, MD:

National Institute on Alcohol

Abuse and Alcoholism, 1995.

Minnesota Department of Human

Services Chemical Dependency

Division. Treatment retention

for women in women-only versus mixed-gender programs: A

preliminary report. Research

News July:1-8, 1995.

Mondanaro, J.E.; Wedenoja, M.;

Densen-Gerber, J.; Elahi, J.;

Mason, M.; and Redmond,

A.C. Sexuality and fear of intimacy as barriers to recovery for

drug dependent women. In:

Beschner, G.M.; Reed, B.G.;

and Mondanaro, J., eds.

Treatment Services for Drug

Dependent Women. Vol. 2.

National Institute on Drug

Abuse Treatment Monograph

Series. Washington, DC:

National Institute on Drug

Abuse, 1982.

National Evaluation Data and

Technical Assistance Center

(NEDTAC). Women, Violence,

and Substance Abuse: Selected

Bibliographies, 1990-1998. Prepared for the Center for

Substance Abuse Treatment by

NEDTAC, April 1998. Available

on the Internet: NEDTAC 1998

[http://www.calib.com/nedtac].

National Institute of Justice. Drug

Use Forecasting. Washington,

DC: National Institute of

Justice, 1991.

National Institute of Justice.

Intervening With SubstanceAbusing Offenders: A Framework

for Action; The Report of the

National Task Force on

Correctional Substance Abuse

References

159
Strategies. Washington, DC:

U.S. Department of Justice,

1991.

National Institute of Justice. 1996

Drug Use Forecasting: Annual

Report on Adult and Juvenile

Arrestees. Washington, DC: U.S.

Department of Justice, 1997.

NIJ Research In Brief. DrugAbusing Women Offenders:

Results of a National Survey.

Washington, D.C.: National

Institute of Justice, October

1994.

National Institutes of Health.

Methods for voluntary weight

loss and control. NIH

Technology Assessment Statement

Online 10:March 30-April 1,

1992.

National Institutes of Health.

Effective Medical Treatment of

Opiate Addiction. NIH Consensus Statement 15(6):1-38,

November 17-19, 1997. NIH

consensus statement no.108 is

available in electronic form on

the World Wide Web from:

http://consensus.nih.gov/

consensus statements/[choose

pharmacology].

National Opinion Research

Center and Lewin-VHI, Inc.

Evaluating Recovery Services:

The California Drug and Alcohol

Treatment Assessment (CALDATA) General Report. Sacramento,

CA: California Department of

Alcohol and Drug Programs,

1994. 

Nelson-Zlupko, L.; Kauffman, E.;

and Dore, M.M. Gender differences in drug addiction and

treatment: Implications for

social work intervention with

substance-abusing women.

Social Work 40(1):45-53, 1995.

Newkirk, C.F. Personal communication, 1997.

New Standards, Inc. Betty Ford

Center Treatment Outcomes,

November 1993. St. Paul, MN:

New Standards, Inc., n.d.

New York State Division of

Alcoholism and Alcohol Abuse.

1990 Report on Special Programming for Women: A Position Paper

on Women’s Alcoholism Treatment. Albany, NY: The Division,

1990.

Nielsen, A.L., and Scarpitti, F.R.

Argot use in a therapeutic community. Deviant Behavior: An

Interdisciplinary Journal 16:245-

267, 1995.

Northrup, C. Women’s Bodies,

Women’s Wisdom. New York:

Bantam Books, 1994.

Nowinski, J.; Baker, S.; and Carol,

K. Twelve Step Facilitation

Therapy Manual. Project

MATCH Monograph Series.

Vol. 1. Rockville, MD: National

Institute on Alcohol Abuse and

Alcoholism, reprinted 1995.

Office of Justice Programs, Drug

Courts Program Office. Defining

Drug Courts: The Key

Components, by the National

Association of Drug Court

Professionals Drug Court

Standards Committee. Washington, DC: U.S. Department of

Justice, January 1997.

Office of National Drug Control

Policy. National Drug Control

Strategy. Washington, DC: The

White House, 1992.

Office for Treatment Improvement. Survey of drug program

needs of female offenders. The

Spirit of Recovery 1(2):5, 1992.

Owen, B., and Bloom, B. Profiling

women prisoners: Findings

from national surveys and a

California sample. The Prison

Journal 75(2):165-185, 1995.

Owen, B., and Horwitz, C.

“Women’s Prisons Revisited.”

Paper presented to the

American Society of Criminology, San Francisco, 1991.

Pan, H.; Scarpitti, F.R.; Inciardi,

J.A.; and Lockwood, D. Some

considerations on therapeutic

communities in corrections. In:

Inciardi, J.A., ed. Drug

Treatment and Criminal Justice.

Newbury Park, CA: Sage

Publications, 1993.

Paredes, A. Stepping Out: A

Continuum of Care for County Jail

Inmates; Final Evaluation Report.

Prepared for the Center for

Substance Abuse Treatment.

San Diego, CA: Community

Connection Resource Center,

April 1997.

Peters, R.H. Relapse prevention

approaches in the criminal justice system. In: Relapse

Prevention and the SubstanceAbusing Criminal Offender.

CSAT Technical Assistance

Publications Series, No 8.

Rockville, MD: Center for

Substance Abuse Treatment,

1993.

Peters, R.H. Treatment in jails and

detention settings. In: Inciardi,

J, ed. Drug Treatment and

Criminal Justice. Thousand

Oaks, CA: Sage Publications,

1993.

References

160
Peters, R., and May, B. Drug

treatment services in jails. In:

Leukefeld, C.G., and Tims,

F.M., eds. Drug Abuse Treatment

in Prisons and Jails. National

Institute on Drug Abuse

Research Monograph Series,

No. 118. Washington, DC:

National Institute on Drug

Abuse, 1992.

Peters, R.H.; May, R.L.; and

Kearns, W.D. Drug treatment

in jails: Results of a nationwide

survey. Journal of Criminal

Justice 20:283-297, 1992.

Peyton, E.A. A Coordinated

Approach to Managing the Drug

Involved Offender: The Second

Report of the Treatment Access

Committee, A Permanent Committee of the Delaware Sentencing

Accountability Commission,

March 11, 1994.

Platt, J.J.; Buhringer, G.; Kaplan,

C.D.; Brown, B.B.; and Taube,

D.O. The prospects and limitations of compulsory treatment

for drug addiction. Journal of

Drug Issues 18:505-525, 1988.

Prendergast, M.L.; Wellisch, J.;

and Falkin, G.P. Assessment of

and services for substanceabusing women offenders in

community and correctional

settings, The Prison Journal

75(2):240-256, 1995.

Prendergast, M.L.; Wellisch, J.;

and Wong, M.M. A Study of

Women on Parole Who Graduated

from the Forever Free Substance

Abuse Program: Treatment

Experiences, Needs and Services,

Outcomes Final Report. Los

Angeles, CA: UCLA Drug

Abuse Research Center,

January 4, 1996.

President’s Commission on

Model State Drug Laws.

Socioeconomic Evaluations of

Addictions Treatment, by Center

of Alcohol Studies, Rutgers

University. Washington, DC:

The White House, 1993.

Prochaska, J.O. Presentation at

the ASAM Medical-Scientific

Conference, Atlanta, GA.

Reported in Alcohol and Drug

Abuse Weekly 8(18):1-6, 1996.

Prochaska, J.O., and DiClemente,

C.C. Toward a comprehensive

model of change. In: Miller,

W.R., and Hester, R.K., eds.

Treating Addictive Behaviors:

Processes of Change. New York:

Plenum Press, 1986.

Rapping, E. The Culture of

Recovery. Boston: Beacon Press,

1996.

Reed, B.G. Drug misuse and

dependency in women: The

meaning and implications of

being considered a special

population or minority group.

International Journal of the

Addictions 20:13-62, 1985.

Rogers, B.; Taylor, M.; and

McGee, G. Black Women and

Family Violence: A Guide for

Service Providers, n.d. [Available

from the Minnesota Coalition

for Battered Women, 450 N.

Syndicate St., Suite 122, St.

Paul, Minnesota 55104; phone

651-646-6177].

Root, M.P. Treatment failures: The

role of sexual victimization in

women’s addictive behavior.

American Journal of Orthopsychiatry 59:542-549, 1989.

Roth, J.A. Psychoactive substances and violence. National

Institute of Justice Research in

Brief February:1-8, 1994.

Santiago, L.; Beauford, J.; Campt,

D.; and Kim, S. SISTER Project:

Sisters in Sober Treatment

Empowered in Recovery, San

Francisco County Sheriff’s

Department Final Evaluation

Report. San Francisco, CA:

University of California,

December 1996.

Scarpitti, F.R.; Inciardi, J.A.; and

Pottieger, A.E. Process evaluation techniques for correctionsbased drug treatment programs, Journal of Offender Rehabilitation 19(3/4):71-79, 1993.

Simpson, D.D. National Treatment System Evaluation based

on the Drug Abuse Reporting

Program (DARP) followup

research. In: Tims, F.M., and

Ludford, J.P., eds. Drug Abuse

Treatment Evaluation: Strategies,

Progress and Prospects. National

Institute on Drug Abuse

Research Monograph Series,

No. 51. Rockville, MD:

National Institute on Drug

Abuse, 1984.

Simpson, D.D.; Joe, G.W.;

Broome, K.M.; Hiller, M.L.;

Knight, K.; and Rowan-Szal,

G.A. Program diversity and

treatment retention rates in the

Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors

11(4):279-293, 1997.

Stevens, J.; Arbiter, M.; and

Glider, P. Women residents:

Expanding their role to

increase substance abuse effectiveness in substance abuse

programs. International Journal

of the Addictions 24:425-434,

1989.

References

161
Teplin, L.A. Criminalizing mental

disorder: The comparative

arrest rate of the mentally ill.

American Psychology 39:794-803,

1984. 

Teplin, L.A.; Abram, K.M.; and

McClelland, G.M. Prevalence

of psychiatric disorders among

incarcerated women. Archives

of General Psychiatry 53(6):505-

512, 1996.

Thorne-Finch, R. Ending the

Silence: The Origins and Treatment

of Male Violence Against Women.

Toronto: University of Toronto

Press, 1992.

Turnure, C. The changing roles of

State alcohol and drug agencies in State health care reform.

TIE Communiqué, Center for

Substance Abuse Treatment,

Spring 1995.

UCLA Drug Research Center and

California Department of

Corrections. A Descriptive Study

of Parolee Outcome in Eight

Community Treatment Facilities.

Los Angeles and Sacramento,

CA: UCLA Drug Research

Center and CDOC Office of

Substance Abuse Programs,

December 1995.

U.S. General Accounting Office.

Drug Courts: Information on a

New Approach to Address DrugRelated Crime. Briefing Report

to the Committee on the

Judiciary, U.S. Senate, and the

Committee on the Judiciary,

House of Representatives.

Washington, DC: GAO

(GAO/GGD-95-159BR), May

1995.

Vigdal, G.L., and Stadler, D.W.

Controlling inmate drug use:

Cut consumption by reducing

demand. Corrections Today

51(3):96-97, 1989.

Vlahov, D. HIV-1 infection in the

correctional setting. Criminal

Justice Policy Review 4(4): 306-

318, 1990.

Walker, G.; Eric, K.; Pivnick, A.;

and Drucker, E. A descriptive

outline of a program for

cocaine-using mothers and

their babies. In: Bepko, C., ed.

Feminism and Addiction. New

York: Haworth Press, 1991.

Weinman, B. A coordinated

approach for drug abusing

offenders: TASC and parole.

In: Leukefeld, C.G., and Tims,

F.M., eds. Drug Abuse Treatment

in Prisons and Jails. Washington,

DC: National Institute on Drug

Abuse, 1992.

Wexler, H.K., and Williams, R.

The Stay ‘N Out Therapeutic

Community: Prison treatment

for substance abusers. Journal of

Psychoactive Drugs 18:221-229,

1986.

Wexler, H.K.; Falkin, G.F.; and

Lipton, D.S. Outcome evaluation of a prison therapeutic

community for substance

abuse treatment. Criminal

Justice and Behavior 17:71-92,

1990.

Wexler, H.K.; Falkin, G.P.; Lipton,

D.S.; Rosenblum, A.B.; and

Goodloe, L.P. A Model Prison

Rehabilitation Program: An

Evaluation of the “Stay’n Out”

Therapeutic Community. New

York: Narcotic and Drug

Research, Inc., 1988a.

Wexler, H.K.; Lipton, D.S.; and

Johnson, B.D. A Criminal Justice

System Strategy for Treating

Cocaine- Heroin Abusing Offenders in Custody. National Institute of Justice: Issues and

Practices. Washington, DC:

U.S. Department of Justice,

1988b.

White, E.C. Life is a song worth

singing: Ending violence in the

Black family. In: Burns, M., ed.

The Speaking Profits Us: Violence

in the Lives of Women of Color.

Seattle, WA: Center for the

Prevention of Sexual and

Domestic Violence, 1986.

Yablonsky, L. The Therapeutic

Community: A Successful

Approach for Treating Substance

Abusers. New York: Gardner,

1989.

Yochelson, S., and Samenow, S.E.

The Criminal Personality. Vol.

III. The Drug User. Jason

Aronson, Inc., 1986.

Young, N.K. Invest in Treatment for

Alcohol and Other Drug

Problems: It Pays. Washington,

DC: National Association of

State Alcohol and Drug Abuse

Directors, 1994.

Zankowski, G.L. Responsive programming: Meeting the needs

of chemically dependent

women. Alcoholism Treatment

Quarterly 4(4):53-65, 1987.

Zaplin, R.T., ed. Female Offenders:

Critical Perspectives and Effective

Interventions. Gaithersburg,

MD: Aspen Publishers, Inc.,

1998.

References

162
T

he nine CSAT-supported women’s treatment programs in prisons and jails were asked to suggest

materials used in their programs that could be helpful to others. This Resource List presents a variety

of materials recommended by the CSAT-supported programs for use both by treatment program staffs

and by women participants in treatment programs.

Program Materials (Training Guides, etc.)

Clinical Issues/Training Manuals

Covington, S. S. Helping Women Recover. A PROGRAM FOR TREATING SUBSTANCE ABUSE, SPECIAL EDITION FOR USE

IN THE CRIMINAL JUSTICE SYSTEM. Includes facilitator’s guide and workbook. For ordering and cost information, contact Jossey-Bass Publishers, telephone 800-956-7739, fax 800-605-2665. Internet address:

http://www.josseybass.com

A step-by-step guide that offers mental health professionals tools to implement an integrated treatment

approach to substance abuse and issues of trauma recovery. The Helping Women Recover program is

designed to be implemented in a closed group of six to eight participants.

Covington, Stephanie S. Helping Women Recover. A PROGRAM FOR TREATING SUBSTANCE ABUSE. SPECIAL EDITION

FOR USE IN THE CRIMINAL JUSTICE SYSTEM, A WOMAN’S JOURNAL. For ordering and cost information, contact JosseyBass Publishers, telephone 800-956-7739, fax 800-605-2665. Internet address: http://www.josseybass.com 

A coordinated workbook created to help participants through the healing process. It addresses the special concerns and issues of substance-abusing women in correctional settings.

DiClemente, C.C., and Hughes, S.O. Stages of change profiles in outpatient alcoholism treatment. Journal of

Substance Abuse 2:217-235, 1990.

National Institute on Alcohol Abuse and Alcoholism. Cognitive-Behavioral Coping Skills Therapy Manual.

Project MATCH Monograph Series, Vol. 3, series editor, Mattson, M.E. Rockville, MD: NIAAA, reprinted

1995.

Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing People To Change Addictive Behaviors. New

York: Guilford Press, 1991.

National Institute on Alcohol Abuse and Alcoholism. Motivational Enhancement Therapy Manual, by Miller,

W.R.; Zweben, A.; DiClemente, C.C.; and Rychtarik, R.G. Project MATCH Monograph Series, Vol 2.

Rockville, Maryland: NIAAA, reprinted 1995.

163

Resource List
National Institute of Corrections (NIC). Critical Issues in Managing Female Offenders, 1997. A limited number

of training manuals are available on loan from NIC. For information, call 1-800-877-1461.

National Institute on Alcohol Abuse and Alcoholism. Twelve Step Facilitation Therapy Manual, by Nowinski, J.;

Baker, S.; and Carol, K. Project MATCH Monograph Series. Vol. 1. Rockville, Maryland: NIAAA, reprinted

1995.

Prochaska, J.O.; Norcross, J.C.; and DiClemente, C.C. Changing for Good. New York: William Morrow, 1994.

Time Out for Me. CSAT-sponsored curriculum for women on health and recovery issues. For ordering information, contact J. Randall Webber, Director of Training and Publications via e-mail at rwebber@chestnut.org

or call toll free 1-888-547-8271 or 309-827-6026. Fax inquiries to 309-829-4661, or write to Lighthouse Institute,

Chestnut Health Systems, 720 W. Chestnut Street, Bloomington, Illinois 61701. Internet Web site:

http://www.chestnut.org

Legal Rights of Incarcerated Women

National Women’s Law Center. A Vision Beyond Survival: A Resource Guide for Incarcerated Women, edited by

B.V. Smith and C. Dailard. Washington, DC: the Law Center, 1995. For ordering and cost information, contact the National Women’s Law Center, 11 Dupont Circle, NW, Suite 800, Washington, D.C. 20036, 202-588-

5180.

Criminal Thinking

David Koerner, Mind Over Matters Corrective Thinking, 2-day, 3-day, and 5-day training courses. For ordering

and cost information, contact Rogie Spon at 815-389-0127, or e-mail truthot@aol.com. Web site address on

the Internet: http://www.truthought.com. Address: Truthought, P.O Box 222, Roscoe, Illinois 61073.

National Institute of Corrections (NIC). The Think Curriculum: Cognitive Interventions Program Manual and The

Options Manual. NIC can be contacted at 1860 Industrial Circle, Suite A, Longmont, Colorado 80501, or by

telephone at 1-800-877-1461 or 303-682-0213. Internet address: http://www.nicic.org

Terence T. Gorski (CENAPS model of relapse prevention therapy for use in the criminal justice system):

Catalog of materials and information on training. For course information, contact the CENAPS Corporation,

18650 Dixie Highway, Homewood, Illinois 60430, telephone 708-799-5000, fax 708-799-5032. For ordering

and cost information, contact Herald House/Independence Press, P.O. Box 1770, Independence, Missouri

64055-0770, telephone 816-252-5010, fax 816-252-3976. Internet Web site address: www.heraldhouse.org

Participant Workbooks and Manuals

Cocaine Recovery Workbooks are a series of three workbooks by A.M. Washton that are designed to help recovering cocaine addicts handle the first 90 days of recovery, identify relapse prevention techniques, avoid

“trigger” situations, and check on progress. The workbooks, Quitting Cocaine, Staying off Cocaine, and

Maintaining Recovery, can be ordered on-line (Internet address: http://www.hazelden.com) or from

Hazelden Educational Materials, P.O. Box 11, Center City, Minnesota, telephone 1-800-328-9000.

Quitting Heroin, by C.C. Nuckols, is a workbook that contains a collection of exercises that aid in identifying

the people, places, and situations related to previous heroin use. The workbook helps to develop the

insights and skills used in abstaining from heroin. Available on-line (Internet address:

http://www.hazelden.com) or from Hazelden Educational Materials, P.O. Box 11, Center City, Minnesota,

telephone 1-800-328-9000.

Resource List

164
Walker, Jan. Parenting from a Distance (Danville, Illinois: Interstate, 1987), a text used for inmate students who

are concerned with the impact of incarceration on their children, available in both English and Spanish, and

Parenting from a Distance: Your Right and Responsibilities/Answer Key (Danville, Illinois: Interstate, 1987). These

titles are available from on-line book sellers.

Case Management

Treatment Accountability for Safer Communities (TASC)

1911 N. Fort Myer Drive, Suite 900

Arlington, Virginia 22209

Telephone: 703-522-7214

Fax: 703-741-7698

E-mail : nattasc@aol.com

Staff Training

Criminal Justice-Substance Abuse Cross-Training: Working Together for Change. A curriculum developed by the

Virginia Addiction Technology Transfer Center (VATTC) at Virginia Commonwealth University, with support provided by the Center for Substance Abuse Treatment. Order from VATTC, P.O. Box 980205,

Richmond, Virginia 23298-0205, telephone 804-371-0775, fax 804-828-7862, e-mail: vattc@vcu.edu. Internet

address: http://views.vcu.edu/vattc

Student Handbook: Therapeutic Community Counselor Training. Corrections Research Institute (CRI), October

1996. This 5-day counselor training package includes cross-discipline team building. Order from CRI, 7617

Park, Lenexa, Kansas, telephone 913-962-1075. 

Trainer’s Handbook: Therapeutic Community Counselor Training. Corrections Research Institute (CRI). Order

from CRI, 7617 Park, Lenexa, Kansas, telephone 913-962-1075.

Audio/Video Series; Pamphlets

Beat the Streets: Clean and Sober in the City, a five-part video series on relapse prevention for urban recovery

and chemical dependence. Ordering information: FMS Productions, Inc., 5320 Carpinteria Avenue, No. D,

Carpinteria, CA 93013-2107, telephone 1-800-421-4609, 805-684-7891; fax 805-684-0889.

Beyond the Looking Glass, VHS, 28 minutes, 1994. Available from Hazelden. Internet address:

http://www.hazelden.org, telephone: 1-800-257-7800. Note that other potentially relevant videotapes are

also available from Hazelden.

Commitment to Change: Overcoming Errors in Thinking, a three-part video series with accompanying workbooks by S.E. Samenow. To order, contact FMS Productions, Inc., 5320 Carpinteria Avenue, No. D,

Carpinteria, CA 93013-2107, telephone 805- 684-7891, toll free telephone 1-800-421-4609, fax 805-684-0889.

Family Trap, VHS. Order from Hazelden, Internet address: http://www.hazelden.org or call 1-800-257-7800.

A Framework for Breaking Barriers: A Cognitive Reality, 9-part video series with accompanying workbooks, produced and distributed by Gordon Graham and Company, Inc. To order on-line from the Gordon Graham

Company, visit the Web site: http://www.ggco.com/recovery.htm. Mailing address: Gordon Graham

Company, P.O. Box 3927, Bellevue, Washington 98004, e-mail: automag@pop.nwlink.com, telephone 1-800-

875-3530. 

Resource List

165
A Framework for Recovery, 6- and 12-part video series with accompanying workbooks; produced and distributed by Gordon Graham and Company, Inc. To order on-line from the Gordon Graham Company, visit the

Web site: http://www.ggco.com/recovery.htm. Mailing address: Gordon Graham Company, P.O. Box 3927,

Bellevue, Washington 98004, e-mail: automag@pop.nwlink.com, telephone 1-800-875-3530.

Healing From Childhood Sexual Abuse: A Recovering Woman’s Guide, by K.A. Kunzman. A pamphlet that deals

with the flashbacks, grief, and shame that women face as they heal from incidents of childhood sexual abuse.

Available from Hazelden, Internet address: http://www.hazelden.org or call 1-800-257-7800.

Healing the Wounds of Incest, VHS, 54 minutes—four women and one man, all victims of incest, speak of their

experiences as children and discuss the problems they have faced; Domestic Violence, The Conspiracy of Silence,

VHS, 28 minutes—narrated by Kathleen Turner and featuring Denise Brown, this video outlines the problem

of domestic violence and provides a model for workable solutions; and Season of Hope, VHS, 28 minutes—about

recovering addicts who want to be responsible, nurturing mothers. Available from Pyramid Media, P.O. Box

1048/WEB, Santa Monica, California 90406, 1-800-421-2304 or 310-828-7577. Internet address: http://www.pyramidmedia.com; e-mail, info@pyramidmedia.com.

Living Skills Series: Hygiene and Self-Care, VHS, 20 minutes, 1993. Looking for Work, VHS, 20 minutes, 1989;

Making Decisions VHS, 20 minutes, 1993; Managing Money, VHS, 20 minutes, 1993; Refusal Skills, VHS, 20 minutes, 1993; Values and Personal Responsibility, VHS, 20 minutes, 1993. Order from Hazelden, Internet address:

http://www.hazelden.org or call 1-800-257-7800.

Shame, with Claudia Black, VHS, 30 minutes,1989. Claudia Black defines shame as a chronic feeling of being

defective. Recovery begins with identifying the shaming events and messages from childhood, walking

through the pain, and allowing others to help in the process of reclaiming a healthy self-identity. Available

from MAC Publishing, 321 High School Road NE, No. 346, Bainbridge Island, Washington 98110. Telephone:

1-800-698-0148, 206-842-6303, fax 206-842-6235. Also available from Hazelden, Internet address:

http://www.hazelden.org or call 1-800-257-7800. 

Oxford Houses

Oxford House, Inc.

9312 Colesville Road

Silver Spring, Maryland 20910

Telephone: 301-587-2916

Fax: 301-589-0302

Internet address: www.icagroup.org

Oxford House is a concept in recovery from drug and alcohol addiction. In its simplest form, an Oxford

House describes a democratically run, self-supporting, and drug free group home. Parallel to this concept

lies the organizational structure of Oxford House, Inc. This publicly supported, nonprofit 501(c)3 corporation is the umbrella organization that provides the network connecting all Oxford Houses and allocates

resources to duplicate the Oxford House concept where need arises. Oxford Houses include men’s houses,

women’s houses, and houses for women with children.

Resource List

166
Screening and Assessment Instruments

For general information on assessment and evaluation instruments:

The ERIC Clearinghouse on Assessment and Evaluation

Educational Resources Information Center

Web site: http://ericae.net

The Catholic University of America

210 O’Boyle Hall

Washington, DC 20064-4035

Telephone: 800-848-4815; 614-292-4353

DSM-IV

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

Washington, DC: American Psychiatric Association, 1994. See also “Appendix G—–DSM-IV Criteria for

Substance-Related Disorders,” in the Center for Substance Abuse Treatment’s Assessment and Treatment of

Cocaine-Abusing Methadone-Maintained Patients. Treatment Improvement Protocol (TIP) Series, No. 10. DHHS

Pub. No. (SMA) 94-3004, Rockville, MD: CSAT, 1994. TIPs can be ordered from the National Clearinghouse

for Alcohol and Drug Information (NCADI), 800-729-6686 or 301-468-2600.

Addiction Severity Index (ASI)

The Addiction Severity Index (ASI) is a multidimensional, 161-item structured interview that takes approximately 45 minutes to complete and score.

To obtain electronic, disk, or paper copies of the various editions of the ASI instrument, as well as supplementary materials, contact the Treatment Research Institute at the University of Pennsylvania via the ASI

help line: 800-238-2433. These materials will be provided for the cost of shipping and handling.

The developer of the ASI form and administration manual is:

A. Thomas McLellan, Ph.D.

Department of Psychiatry

University of Pennsylvania

Philadelphia, PA 19104

215-823-6095

ASAM Patient Placement Criteria

American Society of Addiction Medicine

4601 N. Park Avenue

Chevy Chase, MD 20815-4519

Telephone: 301-656-3920

The following books are available through ASAM:

American Society of Addiction Medicine (ASAM). Patient Placement Criteria for the Treatment of Psychoactive

Substance Use Disorders, by Hoffmann, N.G.; Halikas, J.A.; Mee-Lee, D.; and Weedman, R..D.

American Society of Addiction Medicine (ASAM). The ASAM Patient Placement Criteria, 2nd ed. Updating,

Understanding and Using the Criteria, by David Mee-Lee.

Resource List

167
For more information about the ASAM criteria, the reader is also referred to CSAT’s Treatment Improvement

Protocol: Guide to Substance Abuse Services for Primary Care Clinicians, Lee Gartner and David Mee-Lee,

Consensus Panel Co-chairs. Treatment Improvement Protocol (TIP) Series, No. 24. Rockville, MD: CSAT,

1998. See especially chapter 3, “Critique of Existing Criteria.” To order, contact the National Clearinghouse

for Alcohol and Drug Information (NCADI) 1-800-729-6686 or 301-468-2600. Also note that the Recovery

Attitude and Treatment Evaluator (RAATE-CE for clinical evaluation) and RAATE-QI (questionnaire I) are

assessment of severity tools designed for compatibility with the ASAM Patient Placement Criteria. See the

listing later in this section.

Beck Depression Inventory (BDI)

The Beck Depression Inventory is a 21-item, paper and pencil self-report depression rating scale that

requires about 15 minutes to complete.

The manual and 25 record forms cost $41 and may be ordered from:

The Psychological Corporation

555 Academic Court

San Antonio, TX 78204

Telephone: 800-228-0752

Minnesota Multiphasic Personality Inventory (MMPI)

Order from:

National Computer Systems

P.O. Box 1416

Minneapolis, MN 55440

Telephone: 1-800-627-7271, ext. 5151

Web site: http://www.ncs.com

Multidimensional Addictions and Personality Profile (formerly Compass), by John Craig. An assessment tool

for addictions and a screening tool for life skills and psychological issues. 

Order from:

Diagnostic Counseling Services

P.O. Box 6178

Kokomo, Indiana 46904-6178

Telephone: 1-800-292-4968

Recovery Attitude and Treatment Evaluator

Clinical Evaluation (RAATE-CE) and Questionnaire I (RAATE-QI)

The RAATE-CE and RAATE-QI are assessment of severity tools designed for compatibility with the ASAM

Patient Placement Criteria. The RAATE-CE is a 35-item structured interview that requires approximately 20 to

30 minutes. The RAATE-QI is a 94-item self-report that takes patients about 30 to 45 minutes to complete.

The tools may be ordered from:

New Standards, Inc.

1080 Montreal Avenue, Suite 300

St. Paul, MN 55116

Telephone: 800-755-6299

Fax: 612-690-1303

Resource List

168
The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). Used to assess readiness and

commitment to change.

Author: William R. Miller

Distributor:

William R. Miller

Department of Psychology

University of New Mexico

Albuquerque, New MM 87131

Symptom Checklist-90-Revised (SCL-90-R)

Author: Leonard R. Derogatis

Contact:

National Computer Systems

Telephone: 1-800-627-7271, ext. 5151

Fax: 612-939-5199

Web site: www.ncs.com/assessments

Resource Centers on Women’s Materials

National GAINS Center for People With Co-Occurring Disorders

in the Justice System (GAINS)

262 Delaware Avenue

Delmar, New York 12054

Telephone: 1-800-311-GAIN and 518-439-7415; fax 518-439-7612

Internet address: http://www.prainc.com

The GAINS Center is supported by the Center for Substance Abuse Treatment, the Center for Mental Health

Services, and the National Institute of Corrections. The GAINS Center can provide resources, information,

and technical assistance documents on women with co-occurring disorders in the criminal justice system. A

new resource is the Women’s Program Compendium, a comprehensive guide to the 54 programs that offer services to women in the criminal justice system who have co-occurring mental health and substance abuse disorders. The Compendium is organized by State.

National Women’s Health Information Center (NWHIC)

Operated by the U.S. Department of Health and Human Services

Monday through Friday: 9 a.m.–6 p.m. EST

Telephone: 1-800-994-WOMAN

Internet address: http://www.4woman.org

The National Women’s Health Information Center (NWHIC) is sponsored by the U.S. Public Health

Service’s Office on Women’s Health, with support from a number of different Federal agencies. NWHIC is

a one-stop gateway for women’s health resources and materials for consumers and professionals; it has an

extensive Web site. The Web site delineates the Federal approach to women’s health and includes a section

on women of color.

Resource List

169
The Stone Center

Wellesley College

106 Central Street

Wellesley, Massachusetts 02481

Telephone: 781-283-2500

Internet address: http://www.wellesley.edu/WCW/scsub.html

The Stone Center can provide a wide variety of inexpensive materials that concern the treatment of women,

including working papers, audiotapes, books, videotapes, and project reports. Materials are available on

such topics as the relational development of women, anger/depression/shame, diversity, family relationships/adolescents/children, gender relations, lesbian relationships, and power/effectiveness.

Drug-Related Federal Clearinghouses

National Clearinghouse for Alcohol 1-800-729-6686

and Drug Information (NCADI) 301-468-2600

Operated by the Center for Substance Abuse Prevention (DHHS)

Monday through Friday: 9 a.m.–6 p.m.

Internet address: http://www.health.org

NCADI disseminates a wide range of materials on drug education, prevention, and treatment, including

Federal Government publications, fact sheets, posters, audiovisual materials, prevention curricula and program descriptions, comprehensive prevention resource guides, and articles. The clearinghouse maintains an

extensive full-service library and coordinates the Regional Alcohol and Drug Awareness Network (RADAR),

which facilitates access to State and local sources of information about alcohol and other drugs.

CDC National Prevention Information Network 1-800-458-5231

Monday through Friday: 9 a.m.–6 p.m. EST

Internet address: http//www.cdcnpin.org

The CDC National Prevention Information Network (NPIN) is a national reference, referral and distribution

service for information on HIV/AIDS, sexually transmitted diseases (STDs), and TB, sponsored by the Centers

for Disease Control and Prevention (CDC). All of NPIN’s services are designed to facilitate the sharing of information and resources among people working in HIV, STD, and TB prevention, treatment, and support services. NPIN staff serve a diverse network of people who work in international, national, State, and local settings.

Drug Abuse Information and Treatment Referral Line 1-800-662-HELP

Operated by NIDA and the Center for Substance

Abuse Treatment (DHHS)

Spanish: 1-800-66-AYUDA

Monday through Sunday: 24 hours a day

Internet address: http://www.health.org

Provides information about drug use, treatment support groups, and services. Information counselors can

discuss problems and provide referrals to State and local drug treatment facilities and programs.

Resource List

170
National Criminal Justice Reference Service (NCJRS) 1-800-851-3420, ext. 8

Operated by the National Institute of Justice (DOJ) 301-519-5000

Monday through Friday: 8:30 a.m.–7 p.m.

Nonoperational on Thursdays 8-9 a.m. EST

Internet address: www.ncjrs.org

Provides information and data on drug testing; drug control enforcement; sentencing and corrections policies

for drug offenders; drug abuse prevention and treatment in criminal justice settings; drug-related crime;

research evaluation strategies; and specialized bibliographic searches. NCJRS maintains a library, a large computerized database and microfilm collection, and a special resource package and compact disc (CD-ROM)

library on drugs and crime. Clearinghouse resources and activities can also be accessed through the NCJRS

electronic bulletin board at 301-738-8895.

ONDCP Drug Policy Information Clearinghouse 1-800-666-3332, press 2

Operated by the Office of National Drug Control Policy (ONDCP)

Fax: 301-519-5212

Monday through Friday: 8:30 a.m.–5:15 p.m.

Internet address: http://www.whitehousedrugpolicy.gov

Collects, analyzes, and distributes data on drugs and crime, with a special emphasis on serving the data

needs of State and local government agencies. The Clearinghouse offers access to a library and specialized

bibliographic data bases, including Federal drug data sources and special reports on drugs and crime. The

Center provides free an updated directory of contacts at State agencies concerned with drug abuse. Order

State Drug Resources: 1994 National Directory (NCJ-147709). An updated version, State Drug Resources: 1997

National Directory, is available on-line only at the Internet address listed above. The Clearinghouse offers

documents on women and housing.

Other Sources of Drug Abuse and

Criminal Justice-Related Information

Anti-Drug Information Center 1-800-225-3784

Operated by the Department of Transportation (DOT) 202-366-3784

Computer modem: 1-800-225-3804 Fax: 202-366-3897

Monday through Sunday: 24 hours a day

Internet address: http://www.dot.gov/ost/dapc

Provides immediate access to all regulatory information related to DOT’s antidrug programs. Phone menus

offer summaries of antidrug regulations, answers to commonly asked questions, a current list of certified

drug-testing labs, a free catalog listing documents available via fax, and mail or fax delivery of specific documents.

BJS Clearinghouse 1-800-732-3277

Bureau of Justice Statistics Clearinghouse Fax: 1-410-792-4358

P.O. Box 179, Dept. BJS

Annapolis Junction, Maryland 20701-0179

Internet address: http://www.ojp.usdoj.gov/bjs/

Operated by the Bureau of Justice Statistics (BJS). This Clearinghouse is a component of the National

Criminal Justice Reference Service. It provides criminal justice statistical information.

Resource List

171
Juvenile Justice Clearinghouse 1-800-638-8736

P.O. Box 6000

Rockville, Maryland 20849-6000

Internet address: http://www.ncjrs.org

Operated by the Office of Juvenile Justice and Delinquency Programs, Office of Justice Programs,

Department of Justice.

National Evaluation Data and Technical Assistance (NEDTAC) 1-800-7-NEDTAC

1-703-385-3200

10530 Rosehaven Street, Suite 400 Fax: 1-703-385-3206

Fairfax, Virginia 22030

Internet address: http://www.calib.com

The mission of the National Evaluation Data and Technical Assistance Center (NEDTAC) is to develop and

implement a program evaluation system and evaluation resource center that will enhance substance

abuse treatment service delivery and effectiveness. NEDTAC serves CSAT staff, CSAT grantees, and substance abuse treatment evaluators. NEDTAC products include bibliographies and reference papers that

can be downloaded through its Web site.

Resource List

172
Consultant

Reviewers

Mary E. McCaul, Ph.D.

Consultant

Comprehensive Women’s Center

Baltimore, Maryland

Cassandra F. Newkirk, M.D.

Consultant

Caldwell, New Jersey

Field Reviewers

Virgil Barrett

Program Analyst

Department of Public Health

Coordinating Office for Drug

and Alcohol Abuse Programs

Philadelphia, Pennsylvania

Margaret L. Beaudry

Director of Research

Drug Strategies

Washington, D.C.

Barbara Bloom, Ph.D.

Consultant

Barbara Bloom & Associates

Petaluma, California

Sandra Buell

Treatment Administrator

Arkansas Department of

Community Punishment

Little Rock, Arkansas

Linda Clays, CADC II

Program Coordinator

Tualatin Valley Centers

Salem, Oregon

Stephanie Covington, Ph.D.,

L.C.S.W.

Co-Director

Institute for Relational

Development

La Jolla, California

Bonnie Cypull, M.S.W.

Manager of Treatment

Enhancement Projects

Baltimore Substance

Abuse Systems

Baltimore, Maryland

Marilee L. Dal Pra

Project Director

Maricopa County Adult

Probation Department

Phoenix, Arizona

Laura DeRiggi, L.S.W.

Clinical Coordinator

Coordinating Office for Drug

and Alcohol Abuse Programs

Philadelphia, Pennsylvania

Gwen Empson, B.A., CAC,

CADC

Program Director

Delores J. Baylor Women’s

Correctional Institution

WCI Village TC Program

Correctional Medical Services

New Castle, Delaware

Ernest Jarman

Project Director

Office of Substance

Abuse Programs

California Department

of Corrections

Sacramento, California

Ramona Massey

Program Director

Sisters in Sober Treatment 

Empowered in Recovery

(SISTER) Program

San Francisco, California

Kathleen L. Mayer

Program Manager

York Correctional Institution

Niantic, Connecticut

Lucia Meijer

Project Director

Incarcerated Women’s 

Recovery Program

North Rehabilitation Facility

Seattle, Washington 

Anita Paredes, M. Ed.

Deputy Director

Community Connection

Resource Center

San Diego, California

Elizabeth Peyton

Consultant

Newark, Delaware

173

Appendix—List of Reviewers
Deborah Raddock, M.A.

Director, Treatment

Philadelphia Industrial

Correctional Center

Philadelphia Prisons System

Philadelphia, Pennsylvania

Pamela F. Rodriguez, M.A.

Director of Program Services

Treatment Alternatives for

Safer Communities (TASC)

Chicago, Illinois

Michal Rubin, Ph.D., MAC

Consultant

Columbia, South Carolina

Glenda Spratt

Grants Coordinator

Arkansas Department

of Community Punishment

Little Rock, Arkansas

Barbara Hanson Treen

Executive Director

WomenCare, Inc.

New York, New York 

Beth A. Weinman

National Drug Abuse

Programs Coordinator

Federal Bureau of Prisons

Washington, D.C.

Appendix—List of Reviewers

174
Other Technical Assistance Publications (TAPs) include:

TAP 1 Approaches in the Treatment of Adolescents with Emotional and Substance Abuse

Problems PHD580

TAP 2 Medicaid Financing for Mental Health and Substance Abuse Services for Children and

Adolescents PHD581

TAP 3 Need, Demand, and Problem Assessment for Substance Abuse Services PHD582

TAP 4 Coordination of Alcohol, Drug Abuse, and Mental Health Services PHD583

TAP 5 Self-Run, Self-Supported Houses for More Effective Recovery from Alcohol and Drug

Addiction PHD584

TAP 6 Empowering Families, Helping Adolescents: Family-Centered Treatment of Adolescents with

Alcohol, Drug Abuse, and Mental Health Problems BKD81

TAP 7 Treatment of Opiate Addiction With Methadone: A Counselor Manual BKD151

TAP 8 Relapse Prevention and the Substance-Abusing Criminal Offender BKD121

TAP 9 Funding Resource Guide for Substance Abuse Programs BKD152

TAP 10 Rural Issues in Alcohol and Other Drug Abuse Treatment PHD662

TAP 11 Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination PHD663

TAP 12 Approval and Monitoring of Narcotic Treatment Programs: A Guide on the Roles of Federal

and State Agencies PHD666

TAP 13 Confidentiality of Patient Records for Alcohol and Other Drug Treatment BKD156

TAP 14 Siting Drug and Alcohol Treatment Programs: Legal Challenges to the

NIMBY Syndrome BKD175

TAP 15 Forecasting the Cost of Chemical Dependency Treatment Under Managed Care:

The Washington State Study BKD176

TAP 16 Purchasing Managed Care Services for Alcohol and Other Drug Abuse Treatment: Essential

Elements and Policy Issues BKD167

TAP 17 Treating Alcohol and Other Drug Abusers in Rural and Frontier Areas BKD174

TAP 18 Checklist for Monitoring Alcohol and Other Drug Confidentiality Compliance PHD722

TAP 19 Counselor’s Manual for Relapse Prevention With Chemically Dependent Criminal

Offenders PHD723

TAP 20 Bringing Excellence To Substance Abuse Services in Rural And Frontier America BKD220

TAP 21 Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional

Practice BKD246

TAP 22 Contracting for Managed Substance Abuse and Mental Health Services:

A Guide for Public Purchasers BKD252

TAP 23 Substance Abuse Treatment for Women Offenders: Guide to Promising Practices BKD310

Other TAPs may be ordered by contacting the National Clearinghouse for Alcohol and Drug Information

(NCADI), (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889.

DHHS Publication No. (SMA) 99-3303

Substance Abuse and Mental Health Services Administration

Printed 1999