Part III—Stages of Treatment Planning: The Action Steps

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

For 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 post-release 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 and other services that the woman will need when she is released back into the community.

Table 10. Continuum of treatment

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 cost-effective 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 Court-Ordered 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 pre-screening 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 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 gender-neutral 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 pre-screen 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 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 30minute 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 Recommendations

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 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, pre-screening 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 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 programs 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 one-third 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 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, one-on-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.
• 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 Inventory-Revised (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 Profile (MAPP), by John Craig, is an assessment tool for addiction and a screening tool for life skills and psychological issues.

• Psychiatric screening (co-occuriing 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.

Table 11. Components of assessment

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 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 train-ing—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 correctional 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 self-esteem 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 self-sufficiency. 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 short term, 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) mid-to 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 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” 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 46 month less intensive programs, such as Forever Free) may include the following:

• Stabilization (detoxification if both educational components and therapeutic interventions and groups)
• 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 post-release 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 full-time 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 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 under-served 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 pre-screen, 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 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 court-ordered or voluntary—about 2½ 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:

• 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 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 self-esteem, 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 self-esteem 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 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 research-oriented 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 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 de-emphasize 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 2week 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 6month 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 directly from completing her in-custody 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 2week 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/Pre-Release 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 crime-free. 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 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 job-hunting 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 post-release 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.
• 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 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 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 pro-bation/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 community-based 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 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: Post-Release 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 12Step 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 follow-up 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).

Components for Post-Release 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 in-custody 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 motiva
tion 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 non-using 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.


Table 12. Paths into community treatment from institutional programs for women offenders with chronic, severe AOD problems

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 drug-free 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.

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 “one-stop” 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 halfway-house 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 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. In-custody 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 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 drug-involved 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 sub-stance-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 1½ 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 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 women-focused 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 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.

Table 13. Selected approaches for case management

This ACT case management model has been specifically applied to high-risk drug-involved 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.
• 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 community-based 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 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 Ex-Offenders 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 no-treatment 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 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 community-based 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 alcohol-free 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).

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 mutual-help group is available that was created by and for ex-offenders. 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 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 mutual-help support network for sub-stance-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 ex-offenders 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.

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