Chapter 2—Specific Treatment Approaches for Women Offenders

The 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 drug-dependent, 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 all-female 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. 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 all-woman 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 Program 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 all-women 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.

Table 3. Characteristics of CSAT Demonstration Programs for Women Offenders

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 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.

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 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).

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 relation
ship. 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 self-esteem and a sense of self. These approaches appreciate the importance 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 substance-abusing 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).

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 CSAT-supported 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 post-release treatment services is vital.

The most critical period for sub-stance-abusing women offenders is du ring 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.

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