Table Of ContentCGRreIeMn Eet &al .D / ENLEIENDQSU OEFN CWYO /M JAENNU IANR JYA I2L005
10.1177/0011128704267477
Trauma Exposure, Mental Health Functioning,
and Program Needs of Women in Jail
Bonnie L. Green
Jeanne Miranda
Anahita Daroowalla
Juned Siddique
Aconveniencesampleof100femalejailinmateswasinterviewedbytwofemaleclinical
psychologistsusingmeasuresoftraumaexposure,psychopathology,sexualriskbehav-
ior,parentingskills,andperceivedneedsforservice.Participantshadhighratesoflife-
timetraumaexposure(98%),currentmentaldisorders(36%),anddrug/alcoholprob-
lems(74%).Morethanhalfofthewomenshoweddeficitsinparentingskills.Participants
describedtheirprimaryproblemsasbeingintheareasofsubstanceabuseandfamily
issues,andtheyendorsedavarietyofpotentialservicestheywouldliketobeableto
access.Unlesstraumaandvictimizationexperiences,mentalhealthneeds,andfunc-
tionaldifficultiesaretakenintoaccountinprogramdevelopment,incarceratedwomen
are unlikely to benefit optimally from in-house and postrelease programs.
Keywords: incarceratedwomen;jaildetainees;interpersonaltrauma;mentalhealth;
substance abuse; parenting; programming needs
TheBureauofJusticerecentlyreportedthatthenation’sjailpopulation
hasincreasedmorethan40%since1990(U.S.DepartmentofJustice,2003)
withratesofincarcerationincreasingmoreforwomenthanformen.Since
1995,themalepopulationhasrisenby3.8%annually,whereasthefemale
populationhasrisenby5.9%.Thisdramaticgrowthhasbeenattributedto
increasesinillicitdruguseamongwomenalongwithanincreaseindrug-
related convictions and mandatory sentencing (Covington, 1998; Owen &
Bloom,1995;U.S.DepartmentofJustice,1999).Evenso,womeninmates
stillmakeuponly12%ofthejailpopulation(U.S.DepartmentofJustice,
2003).Perhapsforthisreason,relativelylittleattentionhasbeenpaidtothe
BONNIE L. GREEN: Department of Psychiatry, Georgetown University Medical Center.
JEANNE MIRANDA: University of California—Los Angeles Neuropsychiatric Institute,
CenterforHealthServicesResearch.ANAHITADAROOWALLA:TheKingsburyCenter,
Washington,DC.JUNEDSIDDIQUE:UniversityofCalifornia—LosAngelesNeuropsychiat-
ric Institute, Center for Health Services Research.
CRIME & DELINQUENCY, Volume 51 Number 1 January 2005 133-151
DOI:10.1177/0011128704267477
© 2005 Sage Publications
133
134 CRIME & DELINQUENCY / JANUARY 2005
needs of this small but growing population (Koons, Burrow, Morash, &
Bynum, 1997).
Mostincarceratedwomenaremothers;7in10womenundercorrectional
sanction have minor children (U.S. Department of Justice, 1999). Several
studies have examined the impact on children of their mother’s incarcera-
tion,andtheeffectsarequitenegative:Thesechildrensufferemotionaldis-
tress,poorschoolperformance,andaggressivebehavior(Greene,Haney,&
Hurtado, 2000). Yet little is known about the capabilities of incarcerated
womentofulfilltheirparentingrolesoncetheyarereleasedfromprisonor
thevulnerabilitiesoftheirchildrenbasedonpreviousinteractionswiththese
mothers.
Womenprisonershavealsobeenshowntohaveveryhighexposuretoa
varietyoftraumaexperiences,especiallytointerpersonalviolence,including
childhoodphysicalandsexualabuse(Battle,Zlotnick,Najavits,Gutierrez,&
Winsor,2003;Browne,Miller,&Maguin,1999;Greeneetal.,2000;Jordan,
Schlenger, Fairbank, & Caddell, 1996; Owen & Bloom, 1995; Teplin,
Abram,&McClelland,1996).Theyalsohavehighratesofmentaldisorders
and substance abuse (Battle et al., 2003; Jordan et al., 1996; Sanders,
McNeill,Rienzi,&DeLouth,1997;Teplinetal.,1996).Forexample,ina
studyof1,272femalearresteesawaitingtrialattheCookCountyDepartment
ofCorrectionsinChicago(Teplinetal.,1996),60%ofthesamplehadasub-
stanceabusediagnosis,14%metcriteriaforcurrentmajordepression,and
22%metcriteriaforcurrentpost-traumaticstressdisorder(PTSD).Arecent
reviewsuggeststhatexposuretotraumaticeventsisnearlyuniversalamong
incarceratedwomenwithstudiesshowingrangesoftraumaexposuretobe
between77%and90%(Battleetal.,2003),includingarangeofestimatesfor
eachtypeof trauma,butwithallrateswellexceeding thoseinthegeneral
population (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Indeed,
theexperienceoftraumaislikelyadeterminingfactorintheinvolvementin
criminalbehaviorforwomenthroughsuchmechanismsaschildabuselead-
ing to early running away and abuse-related psychopathology like PTSD
leadingtosubstanceabuseforself-medicationpurposes,both,inturn,being
associated with increased risk for criminal behavior (Battle et al., 2003).
ThisworkwasfundedbyPrinceGeorge’sCounty,Maryland,HealthDepartment.Wewouldlike
tothankElishaFriedmanforherhelpinterviewingthewomeninthisstudy.Weacknowledge
MeganMurphyandCarolinedeBenedictusfortheirhelpwithdatacodingandMaryAnnDutton,
LisaJaycox,andStaceyKaltmanfortheircommentsonearlierversionsofthemanuscript.We
thankDellaDonaldsonandWillieNelsonfortheirhelpinfacilitatingsmoothcollectionofdata
withinthejailandforprovidingdataonwomeninmates.Weappreciatetheoversightandguid-
anceofArtThatcher,JoanGleckel,andRobertCulleninconceivingofandremainingcommitted
tothisinnovativeandimportantareaofinvestigation.Finally,wethankthewomenwhopartici-
pated in this project for their willingness to share many aspects of their lives with us.
Green et al. / NEEDS OF WOMEN IN JAIL 135
Trauma exposure, especially interpersonal trauma, is also a significant
predictorofriskyhealthbehaviorsincludingsmoking,substanceabuse,and
risky sexual behavior (Rheingold, Acierno, & Resnick, 2004). HIV risk
behaviorswereexaminedinarecentstudyofwomenprisoners(Huttonetal.,
2001);56%ofthewomenneverorrarelyusedcondoms,and7%had100or
morelifetimesexualpartners.Otherriskbehaviorswerehighaswell,includ-
ingneedlesharing,receptiveanalintercourse,andbeinghighduringinter-
course.PTSDwasindependentlyassociatedwiththepracticeofanalsexand
prostitution, another health risk behavior.
Historically,jailserviceshavebeendevelopedfor,andaremostlygeared
toward,maleinmates.However,recentstudiessuggestthattheneedforser-
vicestargetingwomenandtheirspecificissuesareincreasinglyrecognized.
For example,Koons etal.(1997) didacomprehensivesurveyof stateand
federaladministratorsinsettingswherewomenwereincarceratedtoexam-
inetreatmentprogramsinplaceintheirownjurisdictions.Theareascovered
by these programs included substance abuse education (55%), substance
abusetreatment(47%),programsforparenting(44%),lifeskills(42%),and
relationshipskills(37%).Programsaddressingotherareaswereavailablein
lessthanonequarterofthesurveyedsites,withprograms targetingsexual
abusebeingidentifiedbyonly13%ofprogramsandmentalhealthbeingtar-
geted by only 7% of participants. Administrators indicated that their pro-
gramstendedtotargetfiveormoreareas.Indeed,inspiteofvariousman-
datestoprovideatleastbasicmentalhealthtreatmentinthecriminaljustice
system, only a minority of jails offers a comprehensive range of services
(Steadman,Barbera,&Dennis,1994).Inamoregeneralsurveyofmental
healthservicesinjailsservingbothmenandwomen,Morris,Steadman,and
Veysey(1997)foundthatalthough50%ofthejailstheysurveyedprovided
crisisinterventionandpsychotropicmedications,otherservicesweremuch
less common. Only about a third of the sitesoffered counseling, and only
aboutaquarterreportedofferingdischargeplanning—clearlyacriticalele-
ment in a plan to prevent recidivism.
Although services targeting women and acknowledging their gender-
specific victimization experiences are becoming more common (Welle,
Falkin,&Jainchill,1998)andavarietyofnewlydevelopedservicestargeted
at women inmates’particular needs have been proposed (e.g., Covington,
1998; Zlotnick, Najavits, Rohsenow, & Johnson, 2003), these specialized
servicescontinuetobetheexceptionratherthantherule.Furthermore,data
available to inform creation of appropriate and effective gender-specific
services are still quite limited (Battle et al., 2003; Greene et al., 2000;
Sanders et al., 1997; Welle et al., 1998). Experts generally agree that the
goalsofinterventionandrehabilitationprogramsforincarceratedindividu-
136 CRIME & DELINQUENCY / JANUARY 2005
alsareeconomicandsocialindependence,familyreunification,andreduced
involvementincriminalactivities(Koonsetal.,1997).However,muchisstill
tobelearnedabouttheneedsofwomenprisoners—informationthatcould
informwhattypesofprogramsmightbeacceptedandeffectiveinaddressing
these goals.
Inthisstudy,weexaminedtraumaexposure,mentalhealthproblems,and
substanceabuseissuesamongasampleoffemalejaildetaineesinacounty
facility.Eachareahasstrongimplicationsforthedevelopmentofappropriate
services.Wealsoexpandedthefocusbeyondthesepreviouslystudiedvari-
ablestoincludeseveralotherareasthathaveimportantimplicationsforthe
economic,social,andfamilygoalsdescribedaboveincludingriskysexual
behaviorandparentingcapacity.Finally,weinterviewedthewomenabout
theirownperceptionsofneedandwhatservicestheywouldfindusefulwhile
incarcerated.
METHOD
Procedures
AconveniencesampleoffemaleinmatevolunteersatthePrinceGeorge’s
County Correctional Center participated in this project. All participants
signed up for the study after hearing a presentation; inmates were not
approachedindividually.Thisdesignwasafunctionofdiscussionswithjail
administrators and requirements of the State of Maryland Institutional
ReviewBoard,whichincludedaprisoneradvocate.Ithonoredtheconcerns
ofbothgroupsregardingtheneedforanonymityoftherespondentsinregard
toreportingabuseexperiencesaswellastheneedtoavoidanyrealorappar-
ent coercion for the women to participate.Approximately 125 women are
presentinthisfacilityatagiventime,housedtogetherinonesection,with
staysofvaryinglengths.Somewomenarepretrialdetainees,whereasothers
areservingsentencesfollowingconviction.BetweenAugust2000andJanu-
ary2001,brieforalexplanationsofthestudywerepresentedtowomenresi-
dents of the facility. These presentations were made periodically to insure
thatnewresidentswereawareofthestudy.Duringthepresentation,women
weretoldaboutthenatureofthestudyandthetimerequiredforparticipation.
Aquestion-and-answerperiodfollowed.Interestedwomensignedupforan
interview at a later date. Before beginning the main interview measures,
interviewers reviewed the informed consent procedure in detail with each
volunteertoinsurethatsheclearlyunderstoodtheprocedureandthestudy.
Green et al. / NEEDS OF WOMEN IN JAIL 137
Participatingwomenweregivena$15certificategoodforpurchasesinthe
center store in partial compensation for their time.
Theinterviewtookapproximately1.5to2hourstocomplete.Theinter-
viewers were two female clinical psychologists (Ph.D.s) with clinical and
research interviewing experience.
Measures
The measures used in the study were selected for a variety of reasons
including thewish to keep thetotalamount of timereasonable, theuse of
standardized measures when possible, and the use of measures that the
researchgroupwasfamiliarwithandthatwehadusedinpreviousstudies,
especially studies of low-income, primarily minority women.
Trauma exposure. The trauma screening measure from the National
ComorbiditySurvey(NCS;Kessleretal.,1995)ofthegeneralpopulationof
theUnitedStatesaged15to55wasusedtoassesslifetimehistoryoftrauma.
Twelvecategories of trauma were assessed. The 12 standard itemson this
instrumentweresupplementedwith4additionalitemsdesignedtoovercome
underreportingassociatedwithusingemotionallyladenwordssuchasrape
and abuse. In each case, we followed the item containing an emotionally
ladenwordwithaseconditemthatdescribedthesameexperiencebehavior-
allyandbeganwiththephrase,“Evenifyoudidn’tthinkofitas(event)..,
someone(behavioraldescription).”Forexample,theitemqueryingpartici-
pantsabouthavingbeenrapedwasfollowedbytheitem,“Evenifyoudidnot
thinkaboutitasarape,someone(forexample,aparent,caregiver,spouse,
romanticpartner,acquaintance,orstranger)forcedyoutohaveoraloranal
sexorintercourseagainstyourwillorwhenyouweredruggedorhelpless.”
The items on this scale can be summed to measure the number of trauma
categories the participant has ever experienced.
Substanceabuse.Becausesubstanceabusewasnotaprimaryfocusofthe
study, screening measures were used in this area. The Tweak Test (Chan,
Pristach,Welte,&Russell,1993)wasusedtoassessprioralcoholabuse.This
5-itemmeasureexaminestoleranceforalcohol,worriesorcomplaintsabout
drinking,drinkingduringthemorning,blackouts,andfeelingtheneedtocut
downondrinking.Themaximumscoreis7;thosewithascoreof4ormore
aredesignatedashavinganalcoholproblem.Drugabusewasassessedwith
twosetsofquestionstakenfromtheAlcoholUseDisorderandAssociated
Disabilities Interview Schedule—Alcohol/Drug-Revised (Chatterji et al.,
138 CRIME & DELINQUENCY / JANUARY 2005
1997). Women were asked if they used any drugs or medicines in the 6
months prior to incarceration. Follow-up questions asked about nine drug
categories:(a)sedatives;(b)tranquilizersorantianxietydrugs;(c)painkill-
ers;(d)stimulants;(e)marijuana;(f)cocaine,crack,orheroin;(g)hallucino-
gens; (h) inhalants or solvents; or (i) any other medicines, drugs, or sub-
stances. For the present study, we focused only on illegal drugs, because
abuse of other substances was rarely reported. We designated those who
reportedusingmarijuana,crack,cocaineorheroin,orhallucinogensasillicit
drug users.
Psychiatricdisorders.Thisstudyfocusedonmooddisordersandtheanx-
iety disorder most strongly associated with trauma exposure—PTSD. The
PrimaryCareEvaluationofMentalDisorders (PRIME-MD;Spitzeretal.,
1994)usesDiagnosticandStatisticalManualofMentalDisorders(4thed.;
DSM-IV;AmericanPsychiatricAssociation,1994)criteriatomeasuremood
disordersincludingmajordepressivedisorder(MDD).Itwasusedinalarge
depression treatment trial conducted by the investigators and others
(Miranda et al., 2003), which recruited primarily low-income, minority
women.GoodagreementbetweenthePRIME-MDandindependentpsychi-
atric diagnosis (assessed by a modified version of the Structured Clinical
InterviewforDSM-IV)hasbeenestablished.Wealsoassesseddysthymia,a
chronicdepressiveconditionthatcontinuesfor2yearsormore,andincluded
ascreenerquestionaboutbipolardisorder.PTSDwasevaluatedusingamod-
uleoftheCompositeInternationalDiagnosticInterview(CIDI;Kessleretal.,
1995;WorldHealthOrganization,1997)fromtheNCS,whichfocusesonthe
most distressing traumatic event the women report, and asks about PTSD
symptoms associated with that event.
Sexualandreproductivebehavior.Theseitemsweretakenfromaprevi-
ous study of young adult women done by the research team (Green et al.,
2004) and included questions about menstrual periods, age at first inter-
course,numberoflifetimesexualpartners,useofbirthcontrol,andtestsfor
HIV.Thesetypesofquestionsaresimilartootherstudiesofriskysexualand
reproductive behavior (e.g., Molitor, Ruiz, Klausner, & McFarland, 2000).
Parenting.TheAdult-AdolescentParentingInventory(Bavolek&Keene,
1999)wasusedtoevaluatehowthewomenwerefunctioningasparents.It
consistsof40itemswithwhichtheparticipantagreesordisagreesona5-
point scale.The itemsaddress general attitudesand beliefs about children
and parenting. Subscales measure five specific risk areas: inappropriate
Green et al. / NEEDS OF WOMEN IN JAIL 139
expectations of children, lack of empathy toward children’s needs, strong
beliefintheuseofcorporalpunishmentasdiscipline,reversingparent-child
role responsibilities, and oppressing children’s power and independence.
Themeasurehasbeenextensivelynormedamongindividualsparticipating
incountyagencyprogramsthroughout23states,andeachofthefivescales
discriminatesbetweengroupsofparentsknowntobeabusiveorneglectful
and more general groups.
Perceived Needs
Women were asked an open-ended question about their perceptions of
need(“Asidefromincarceration,whatdoyouseeasyourbiggestproblems
rightnow?”),andtheirresponsesweregroupedintocategories:drugoralco-
holproblems(e.g.,wantingtostayoffdrugs),beingawayfromorworrying
about family (e.g., being away from kids), problems with life direction or
neededskills(e.g.,gettingmyhealthright,gettingmylifeinorder),needing
ajobortraining(e.g.,tryingtogetastablejob),andmiscellaneous.Catego-
riesweremutuallyexclusive.Theywerealsogivenalistofpotentialtypesof
programs(e.g.,drugeducation,GeneralEquivalencyDiploma[GED]prepa-
ration, job training, anger management, parenting skills) and asked which
theywouldliketohaveavailabletotheminjail,andtheywereinvitedtosug-
gest additional areas for programming.
RESULTS
Sample
Onehundredwomenparticipatedinthisproject.Thedemographicchar-
acteristicsofthesamplearepresentedinTable1.Ascanbeseen,thesample
waspredominantlycomposedofyoung,singlewomenwithfairlylowlevels
ofeducationalattainment.Nearlyhalfhadnotcompletedhighschool(44%).
Womenwereaskedabouttheirhealthinsurancestatusasaproxyforsocio-
economicstatus;only15%hadprivateinsurance,22%wereonMedicaid,
andtherest(63%)hadnoinsurance.ParticipantswerepredominantlyAfri-
can American with a smaller White/mixed-race sample. Approximately
threequartersofthewomenhadchildrenyoungerthantheageof18.Most
womenwereawaitingtrial,although20%wereservingacurrentsentence.
Finally,womenwerechargedwithavarietyofcrimesandsometimeswere
multiplycharged(ourcategorieswerenotmutuallyexclusive),butmosthad
140 CRIME & DELINQUENCY / JANUARY 2005
TABLE 1: Demographic Characteristics
Mean (Range) or %
Age 34.5 years (19-50 years)
Marital status
Never married 60%
Married 13%
Divorced/separated/widowed 27%
Education
Less than high school 44%
High school grad/General Equivalency Diploma 31%
Some college or trade school 25%
Ethnicity
African American 81%
White 11%
Other 8%
Child younger than age 18 73%
Living arrangements
With family/friends/parents 65%
In own house/apartment 28%
Other 7%
Legal status
Awaiting trial 80%
Serving sentence 20%
Length of stay
Awaiting trial 1.8 months (1-4 months)
Serving sentence 3.7 months (1-12 months)
Present charges/offense(s)
Assault 18%
Drug related 21%
Theft/robbery/check or credit card fraud 33%
Driving related 9%
Violation of probation 16%
Other 20%
relativelybriefstaysinthejail.Wewereabletoobtainsomedemographic
dataonthelargerpopulationofallwomenwhowereincarceratedatthejail
duringtheyear2000,andoursamplewassimilar.Forthelargergroup,the
mean age was 32.3 years (34.5 years in the present sample), 82% of the
womenwereAfricanAmericanand15%White(comparedto81%and11%
inthepresentsample,respectively),and75%oftheoverallpopulationwere
awaitingtrialcomparedto80%ofthestudysample.Thetwogroupsdiverged
oneducation.Inthelargerpopulation,27%hadlessthanahighschooledu-
cation compared to 44% in the study sample, whereas 47% were listed as
havinga12th-gradeeducationcomparedtoonly31%ofoursample.Therea-
Green et al. / NEEDS OF WOMEN IN JAIL 141
sonfortheeducationdiscrepancyisunclear,butitmakesgeneralizationsto
more educated inmates potentially less valid.
Analyses of study variables showed no significant differences between
AfricanAmericanandotherwomen.Wealsocomparedthesubsamplesof
womenawaitingtrialtothoseservingsentences.Traumaexposurewasquite
similarbetweenthetwogroups(5.4typesoftrauma,onaverage,forthose
awaitingtrialand6.2forthoseservingsentences)aswellastheaveragenum-
berofinterpersonaltraumatypes(3.2versus3.7).Therewerenosignificant
differences between the samples on percentages of psychiatric disorders,
drugabuse,parenting,orriskbehaviors.Thewomenawaitingtrialhadmore
childrenonaverage(2.4comparedto1.6)andlowerpercentagesofanalco-
holproblem(28%comparedto50%)butdidnotdifferoneducationormari-
talstatus.Becausethedifferenceswereminorandthoseservingsentences
were few, the groups were combined for the remainder of the analyses.
Women in the study were also asked about their job training and work
experiences.Nearlyhalfofthewomenreportedsomejobtrainingexperience
priortotheirincarceration,andabouthalfofthoseenteringatrainingpro-
gram completed it. About half of those receiving training were trained in
someaspectofofficeworksuchasdataentry;othersweretrainedincosme-
tology, assistant health technician positions, or manual labor tasks.
Trauma Exposure
Results of the trauma exposure, substance abuse, and mental health
assessmentarepresentedinTable2.Forpurposesofcountingtraumaexpo-
sure, the questions on the NCS measure and the additional corresponding
questionswedeveloped(e.g.,“Evenifyoudidn’tthinkaboutitasabuse...”)
wereaddedtogether.Similartootherstudies,ratesoflifetimetraumaexpo-
surewereextremelyhigh.Intotal,98%ofthewomenhadbeenexposedtoat
leastonecategoryoftrauma.Themostcommontraumaexposurewastovio-
lenceperpetratedbyahusband,partner,orboyfriendwith71%reportingthis
experience.Intotal,62%reportedhavingbeenexposedtochildhoodtraumas
and 90% to at least one type of interpersonal trauma.
Substance Abuse
Substanceabusewascommon,ascanbeseeninTable2.Althoughone
thirdofthesample(34%)reportedthattheydonotdrink,32%wereclassified
bytheTWEAKashavinganalcoholproblem.Nearlythreequarters(72%)
reportedrecentuseofanillicitsubstance,and74%reportedeitheranalcohol
or substance abuse problem.
142 CRIME & DELINQUENCY / JANUARY 2005
TABLE 2: Trauma,Psychiatric Disorders,and Substance Abuse
% Affected
Childhood trauma
Sexually molested 48%
Physically abused 26%
Neglected 25%
Any childhood trauma 62%
Other trauma
Life-threatening accident 42%
Fire, flood, or natural disaster 9%
Witnessed someone injured or killed 58%
Family member killed 58%
Raped 58%
Physically attacked/abused 57%
Domestic abuse 71%
Threatened with a weapon 55%
At least one trauma 98%
Substance abuse problemsa
Alcohol problem 32%
Drug problem 72%
Marijuana 37%
Cocaine, crack, heroin 60%
Hallucinogens 10%
Alcohol or drug problem 74%
Psychiatric disorders
Current major depressive disorder (MDD) 25%
Dysthymia 12%
Possible bipolar disorder 13%
Current post-traumatic stress disorder (PTSD) 22%
MDD, PTSD, or bipolar 36%
a.Substance abuse assessed for the 6 months preceding incarceration.
Mental Health Problems
Althoughnotasfrequentassubstanceabuseproblems,ratesofthepsychi-
atricdisordersstudiedwerehigherthanwouldbeexpectedinthecommunity.
OnefourthofthewomenreportedcurrentMDDand22%hadcurrentPTSD.
Twelvepercentscreenedpositivefordysthymiaand13%forbipolardisor-
der.Addingtogetherthethreemajorcategories(excludingdysthymia),just
more than one third had one of the psychiatric diagnoses.
Sexual and Reproductive Behavior
Womenwereanaverageageof16atthetimeoftheirfirstvoluntaryinter-
course.Nearlyallhadbeenpregnantatleastonce(92%),manyhadmiscar-
