Women with Co-Occuring Substance Use and Mental Disorders int he Criminal Justice System:A Research Review

18 Pages·00.158 MB·English

by  JoAnn Sacks

BehavioralSciencesandtheLaw
Behav.Sci.Law22:449–466(2004)
PublishedonlineinWileyInterScience(www.interscience.wiley.com).DOI:10.1002/bsl.597
Women with Co-Occurring
Substance Use and Mental
Disorders (COD) in the
Criminal Justice System:
A Research Review
JoAnn Y. Sacks, Ph.D.*
Associated with the dramatic increase in the numbers of
womenenteringthecriminaljusticesystemistherecogni-
tion of the prominent role of co-occurring substance use
and mental disorders (COD) in the lives of female offen-
ders.Thisarticlereviewscurrentresearchexaminingthe
prevalenceandrangeofCODamongfemaleoffenders,the
variety of psychosocial problems faced by the female of-
fender with COD, and the multiple treatment needs of
women with COD who are under criminal justice super-
vision. Women with COD can enter the criminal justice
system at several different points and, because both sub-
stance use and mental disorders carry significant risk of
relapse,effectivetreatmentapproachesmustaddressboth
disorders.Thepaperconcludeswithadiscussionofseveral
important treatment issues and provides suggestions re-
garding an agenda for future treatment and research.
Copyright#2004JohnWiley&Sons,Ltd.
INTRODUCTION
Theco-occurrenceofmentalhealthdisordersinsubstanceabusingpopulations,or
of substance abuse disorders in mentally ill individuals, has been a subject of
research interest since the early 1980s (Bachrach, 1987; Center for Substance
Abuse Treatment, in press; Pepper, Kirshner, & Ryglewicz, 1981; Regier et al.,
1990). The most current and widely used definition of ‘‘co-occurring disorders’’
(COD)isthepresenceofoneormoredisordersrelatedtodrugand/oralcoholusein
conjunction with one or more mental disorder (Center for Substance Abuse
Treatment, in press). Within the United States, it is estimated that seven to ten
millionindividualsshowevidenceofCOD(U.S.DepartmentofHealthandHuman
Services,2002).Not surprisingly,CODhas cometobe recognized asasignificant
*Correspondence to: JoAnn Y. Sacks, Deputy Director, Center for the Integration of Research and
Practice(CIRP),NationalDevelopmentandResearchInstitutes,Inc.(NDRI),71West23Street,8th
Floor,NewYork,NY10024,U.S.A.E-mail:[email protected]
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450 J.Y.Sacks
issueforcorrectional populationsaswell.Inthepastdecade, prevalencestudiesin
jailsandprisonshaveidentifiedanincreasingnumberofmenandwomenentering
the criminal justice system with co-occurring substance and mental disorders
(Ditton, 1999; Peters & Hills, 1993; Regier et al., 1990; Steadman, Fabisiak,
Dvoskin, & Holohean, 1987).
Thepasttwodecadeshavewitnessedadramaticincreaseinwomenenteringthe
criminaljusticesystem(Coll,Miller,Fields,&Mathews,1997;Greenfeld&Snell,
1999; Henderson, 1998). As crimes committed by females have increased in both
numberandseverityofoffense,moreattentionhasbeendirectedtowardsdescribing
thechangingpopulationoffemaleoffenders,definingwomen’sneeds,andcreating
gender-sensitive and gender-specific treatment approaches within a variety of
criminal justice settings. Increasingly, the co-occurrence of substance abuse and
mentaldisordershasbeenaccordedparticularimportanceinthedesignoftreatment
programs for female offenders. While a body of knowledge about the incarcerated
female offender suffering from COD and her treatment is accumulating, to date
much of the research information informing treatment has been gleaned from
community-based treatment programs. The purpose of this paper is to review
what is known about the history and treatment needs of women with COD who
are under criminal justice supervision (i.e. prison, jail, diversion, community
correctionsprograms),andtosuggestanagendaforfuturetreatmentandresearch.
BACKGROUND: THE FEMALE OFFENDER
During the past two decades, America’s criminal justice population has evidenced
tremendous growth and, in particular, the number of women in the system has
increasedatanalarmingrate(Colletal.,1997;Henderson,1998).Inthe12years
from1990to2002,thenumberofwomeninfederalandstateprisonsincreasedby
121%(to97,491),whilethenumberofmenroseby84%(to1,343,164).Moreover,
between 1995 and 2001, 49% of the increase in the female prison population was
associatedwiththecommissionofviolentoffenses(Harrison&Beck,2003),75%of
which involved simple assault (Greenfeld & Snell, 1999). In addition, while male
property felonies fell by 2% from 1990 to 1996, female property felonies rose by
44%,themajorityofwhichwereattributedtoariseinconvictionsforforgery,fraud
or embezzlement (Greenfeld & Snell, 1999), possibly a consequence of more
womenenteringtheworkforceatpositions andwithskillsthatenablesuchcrimes.
In2000,thevastmajorityofconvictions resultinginprisonforwomenwerefor
drugoffenses(40%)andpropertycrimes(34%),while18%wereforviolentcrimes
(Harrison & Beck, 2003). Overall, women now comprise 7% of the total prison
population (Harrison & Beck, 2003), and 11% of the jail population (Beck &
Karberg,2001).Recentfigures(1998)indicateannualarrestsof3.2millionwomen,
accounting for 22% of all arrests (Greenfeld &Snell, 1999).
Drug Use Among Females in the Criminal Justice System
Between 1996 and 2001, female arrests for drug offenses increased by 13%
(Harrison & Beck, 2003); in 1998, approximately 272,000 females were arrested
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Womenwithco-occurringdisorders:aresearchreview 451
for drug offenses, accounting for about 18% of all arrests for drug offenses
(Greenfeld&Snell,1999).Theincreaseinfemale incarcerationisoftenattributed
totheincreaseintheabuseofillegaldrugsaswellastheenforcementofincreasingly
punitiveanti-druglaws(Peugh&Belenko,1999).Changesinarrestandsentencing
policiesforstreetleveldrugviolatorsmayaffectwomendrugusersmorethanmen,
since women are reported as more likely to be arrested for drug crimes than for
violentcrimes(Daly&Tonry,1997;Proband,1997).Inthe1980s,women’sdrug
use shifted to crack cocaine, a highly addictive, relatively inexpensive drug. Many
womenreportedengaginginnon-violentcriminalbehavior,suchasprostitutionand
selling crackcocaine, tosupporttheir crackuse(Stevens &Bogart,1999;Stevens,
Estrada,& Estrada, 1998). A significant number of these women have entered the
criminaljusticesystem(Lockwood,McCorkel,&Inciardi,1998),whereupto80%
of inmates areestimated to have substanceabuse problems (Blanchard, 1999).
Indeed,womeninstateprisonsystemsreportedahigherincidenceofdruguseat
thetimeoftheiroffensethantheirmalecounterparts(40%versus32%),aswellas
higher rates of drug use on every measure (e.g. ever used, using regularly, etc.) of
druguseassessed(Greenfeld&Snell,1999).Maleandfemalepatternsofdruguse
differ in other ways as well, with males reporting higher alcohol use and females
higher non-alcohol substance use; female federal prisoners in drug treatment
reported using drugs more frequently and using harder drugs than men (Langan
&Pelissier,2001).Ofthewomenwhoreportdruguse,56%reportparticipatingin
drug treatment at some time prior to incarceration, as opposed to 41% of men
(Greenfeld & Snell,1999).
Gender-related differences in drug use patterns have been found in arrestees as
well as inmates.Among 10,000female arrestees tested and interviewed in 1999 as
part of the Arrestee Drug Abuse Monitoring Program (ADAM), more than 60%
tested positive for at least one drug in 22 of 32 urban sites (National Institute of
Justice, 2000). Cocaine was detected more frequently among female arrestees (25
sites) than among male arrestees (10 sites). Marijuana was the second most
prevalentdrug,followedbymethamphetamine(NationalInstituteofJustice,2000).
Several researchers have posited gender-specific influences on pathways into
substanceabuseandcriminalbehavior(Bloom,Owen,&Covington,2003;Brochu,
Guyon, & Desjardins, 2001), as well as on the recovery process and post-release
recidivism (Pelissier, Camp, Gaes, Saylor, & Rhodes, 2003). A Canadian study
comparing substance-abusing offenders with a community-based treatment sample
foundthatmenandwomenhaddifferentpathwaysintosubstanceabuseandcriminal
behavior. Specifically, substance dependence and delinquency occurred earlier for
womenwhowereincarceratedthanforthosewhowereinsubstanceabusetreatment,
while men showed no comparable differences (Brochu et al., 2001). Gender
differenceshavealsobeennotedinthemultipleproblemsexperiencedbysubstance
usingoffenders.InastudyofFederalprisoners,LanganandPelissier(2001)found
that women suffered greater lifestyle problems related to mental health, childhood
familyenvironment,lackofeducation,adultsocialenvironment,andphysicalhealth.
Theyconcludedthatsubstanceabusetreatmentprogramsdesignedforincarcerated
menmaylackfeaturesneededfortreatmenttobeeffectiveforwomen.
In summary, the increase in female incarceration rate can be attributed to both
the female offender’s substance use and changes in sentencing guidelines. Women
havehigherratesofdruguseanddifferentpatternsofusefrommen.Gender-related
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452 J.Y.Sacks
differences between female and male offenders have been detected in rates of
substance use, patterns of drug and alcohol use, early pathways into substance
abuseandcriminalbehavior,andtheprevalenceoflifestyleproblems,includingco-
occurring mental disorders. All of these gender-related differences carry implica-
tions that underscore the need for gender-specific treatment programming.
Mental Disorder Among Females in the
Criminal Justice System
Theprevalenceofmentaldisordershasbeenfoundtobehigherintheprisonsystem
than in the general population (Brinded, Simpson, Laidlaw, Fairley, & Malcolm,
2001; Fazel & Danesh, 2002; Diamond, Wang, Holzer, Thomas, & des Anges
Cruser,2001;O’Brien,Mortimer,Singleton,&Meltzer,2003).Withinthecriminal
justice system, the proportion of offenders with mental illness disorders has been
estimatedas16%ofinmatesinbothstateprisonsandlocaljails,and7%offederal
inmates(Ditton,1999);clinicalstudieshavesuggestedthattheincidenceofserious
mentalillnessinColoradoprisonshasmorethantripledinthepast10years,from
4%in 1991to14%in 2001 (Kleinsasser&Michaud,2002);approximately three-
quarters of these have aco-occurring substance use disorder.
ThepictureinjailsettingsisilluminatedfurtherwithdatafromNewYorkState.In
astudyofentriesintoNewYorkStateprisons,jails,andmentalhealthfacilitiesover
fiveyears,Cox,Banks,andStone(2000a)foundthatthetotalvolumeofindividuals
being treated for mental disorders was higher in jails than in state prisons, mainly
because those in jails had committed less serious crimes and were given shorter
sentences. In comparing the total number of offenders who enter jails and prisons,
femalerecipientsofmentalhealthserviceswere17.6timesmorelikely,andmaleswere
8.9timesmorelikely,tohaveenteredjailthanprison(Cox,Banks,&Stone,2000b).
Ascomparedwithmaleoffenders,womenwithinthecriminaljusticesystemare
morelikelytobeidentifiedasmentallyill(Ditton,1999).Thementalhealthissues
ofdrug-usingwomeninprisonsarereportedtobemoredistinctandpervasivethan
among men (Wilcox & Yates, 1993; Windle, Windle, Scheidt, & Miller, 1995).
Compared with men, women prisoners were more likely to report depression,
anxiety, low self-esteem, and use of prescribed medications for psychological
problems (Peters, Strozier, Murrin, & Kearns, 1997). In a review of 62 surveys
(involving23,000prisoners)from22Westerncountries,FazelandDanesh(2002)
found that 12% of women prisoners had experienced major depression within
the past 6 months, as compared with 10% of men, and that 21% had antisocial
personality disorder as compared with 47% of men. In a study of state and
federal prisoners, Megargee, Mercer, and Carbonell (1999) found that female
offenderprofilesontheMMPI-2weremoredeviantthanprofilesofmaleoffenders.
Therateofseriousandothermentaldisordersishighforwomeninjailandprison
settings. Among admissions to county jails, 12% of women were diagnosed with
mental disorders (Teplin, personal communication), and a national sample of
female arrestee populations reported diagnoses of serious mental disorders for
7%,anxietydisordersfor11%,dysthymiafor8%,andAxisIIantisocialpersonality
disorders for 45% (National GAINS Center, 1997). Among female offenders
entering prison, 59% had at least one mental disorder, excluding substance
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Womenwithco-occurringdisorders:aresearchreview 453
abuse/dependence, yet prison screening identified only slightly over one-third
(Parsons, Walker, & Grubin, 2001), which indicates that the presence of mental
disorders among women in the criminal justice system may be under-reported. A
comparison of female prisoners, both with and without a history of mental health
treatment, found that those who had previously used mental health services were
morelikelytohaveahistoryofalcohol,cocaine,heroin, andmarijuanaabuse,and
were more likely to be under-educated, unemployed, and parents (Marquart,
Brewer, Simon, & Morse, 2001).
Female offenders are more likely than males to be diagnosed with a mental
disorder, report psychological distress including depression, and to have more
pervasive psychological symptoms and problems. Female prisoners with mental
disordersaremorelikelythanthosewithoutmentaldisorderstohaveaco-occurring
substancedisorder.Thesefindingsneedtobeconsideredinthedesignoftreatment
programsfor women offenders.
Co-Occurring Substance and Mental Disorders
Among Females in the Criminal Justice System
As compared with the general population, men and women with COD are at high
risk of incarceration (Rock, 2001; Munetz, Grande, & Chambers, 2001). The
relatively small number of studies to examine COD among female offenders
suggests that these women contact the criminal justice system through crimes
related to substance use, and that their co-occurring mental health problems are
discovered on entering the system, whether through jail, prison, or drug court
diversionprograms(Hills, 2003;Peters&Osher, 2003).The patterns of CODfor
womenincriminaljusticesystemsaresimilarto,butoftenmoreseriousthan,those
foundincommunitystudies.Inapopulationoffemalearrestees,86%werefoundto
have at least one substance use disorder and 94% evidenced significant psycholo-
gical distress (Heffernan, Finn, Saunders, & Byrne, 2003). In a recent study of
female jail detainees with current severe mental disorders (i.e. major depression,
bipolar disorder), nearly three-quarters were found to meet diagnostic criteria for
one or more substance use disorder (Abram, Teplin, & McClelland, 2003).
Incarceratedsubstanceabusingwomenaremorelikelytohaveaco-existingmental
disorder(Henderson,1998)andfemaleoffenderswithmentalillnessreportahigh
incidence of co-occurring drug and alcohol abuse (Diamond et al., 2001; Ditton,
1999). Female inmates, as compared with women in community epidemiologic
studies, have been found to have elevated rates of substance and mental health
disorders, including substance abuse and dependence, mood disorders, borderline
personality, and antisocial personality (Jordan, Schlenger, Fairbank, & Caddell,
1996; Maden, Swinton, & Gunn, 1994), as well as elevated rates of lifetime
exposure totraumatic events (Jordanet al., 1996).
TREATMENT ISSUES FOR WOMEN WITH COD IN
THE CRIMINAL JUSTICE SYSTEM
Theneedsofwomeninthecriminaljusticesystemhavebeendescribedasdifferent
from,greaterthan,andmorecomplexthanthoseofmen(NationalGAINSCenter,
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454 J.Y.Sacks
1999). Many gender-specific issues contribute to the special treatment needs of
women in the criminal justice system. Increasingly, it is recognized that these
women suffer from pervasive life problems, often untreated or under-treated as
theyenterandmovethroughthesystem.Despitethehighprevalenceofsubstance
abuseandmentalhealthdisordersinthecriminaljusticesystem,fewwomenreceive
substance abuse services while in prison (Mumola, 2000). As yet, relatively few
treatment programs are available to women in criminal justice, and current
programming is typicallybased on male treatmentmodels (Peters et al., 1997).
Inarealsense,theproblemstypicallyfacedbyafemaleoffenderpopulationare
compoundedbyCOD.Theseproblems,whichrequireattentionforcriminaljustice
treatment to be effective, are appropriatefor abrief review.
Abuse and Victimization Among Females in the
Criminal Justice System
Abuseandvictimizationhavebeenidentifiedasmajorfactorsinthelifehistoriesof
women engaging in criminal behavior. Fifty to sixty percent of women in the
criminal justice system are reported to have experienced childhood and/or adult
physical and sexual abuse (Browne, Miller, & Maguin, 1999; Bureau of Justice
Statistics, 2001; Coll et al., 1997; Greenfeld & Snell, 1999; McNamara & Fields,
2002;Radosh,2002;Warrenetal.,2002).Theseratesaresubstantiallyhigherthan
those found in the general population, reported as approximately 33% for women
(Gil-Rivas, Fiorentine, Anglin, & Taylor, 1997); Teplin, Abram, and McClelland
(1996)speculatethatthetrueprevalenceoflifetimeabuseandvictimizationamong
female offenders may be even higher, given the reluctance of women to discuss
traumatic and upsettingevents.
Many offenders report a history of early childhood abuse, which has been
associated with higher rates of violent crime (Harlow, 1999), higher risk sexual
activities (Mullings, Marquart, & Hartley, 2003), and symptoms associated with
PTSD (O’Keefe, 1998). Examining gender differences in childhood and adult
maltreatment and subsequent substance use and criminality, McClellan, Farabee,
andCrouch(1997)foundthatfemaleinmatesreportedsignificantlymoreabuseas
children and that, while the abuse of men drops sharply as they reach adulthood,
abuse of women actually increases. Among female offenders, physical and sexual
abuse has been associated with incarceration for violent crimes (Bureau of Justice
Statistics,1997),druguseandhighrisksexualbehaviors(Mullingsetal.,2003),the
occurrenceofCOD(Alexander,1996),andinmatesuicidalideationand/orbehavior
(Blaauw,Arensman,Kraaij,Winkel,&Bout,2002).Thepotentialconsequencesof
abuse among female offenders include a complex of symptoms associated with a
diagnosis of PTSD, as reported by Teplin and colleagues (1996), who found that
over 30% of female jail detainees with a history of abuse met criteria for PTSD, a
higher proportion than the 22% found in a community-based treatment sample of
cocaineabusingwomen(Najavitsetal.,2003).Itshouldbenotedthat,amongthose
not meeting criteria for PTSD in the community treatment sample, substantial
traumaandsub-thresholdPTSDsymptomswereevident(Najavitsetal.,2003).
Trauma-sensitive criminal justice approaches (ones less likely to mimic assaults
or abuses or exacerbate symptoms) have been developed for working with
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Womenwithco-occurringdisorders:aresearchreview 455
incarceratedwomen(Clark,2002),includingtalkingwomenthrougha‘‘patdown’’
(i.e.physicalsearchforcontraband)usingfemalestaff,incorporatingtraumaissues
into various treatment modalities, and providing training in trauma-sensitive
approachestoallcorrectionalandcorrectionalsocialservicestaff(TAMARProject,
1998).
There hasbeen little research concerning trauma-specific treatment approaches
withincorrectionalsettings.Apilotstudyhasreportedpromisingshort-termPTSD
symptom and substance use outcomes for incarcerated women using a trauma-
specific treatmentapproach;however,thesmallsample size(n¼17)andrelatively
short post-prison follow-up period (3 months) limits the generalizability of the
results (Najavits, 2003).
The prevalence of adult and childhood abuse in the lives of female offenders,
especially those with substance abuse problems, and the psychosocial dysfunction
associated with a history of trauma, leads to the inference that an assessment of
lifetime trauma would point to improvements in treatment planning, and to
enhancements in treatment and correctional interventions with benefits accruing
to asignificant number of such women in criminal justice settings.
Gender-Specific Security and Treatment Approaches
Developing trust between women inmates and staff, as well as safety and trust
amongwomeninmatesthemselves,arecriticaltothetreatmentprocess ifsensitive
issues such as sexual and physical abuse are to be addressed. With particular
reference to boot camp programs, Veysey, De Cou, and Prescott (1998) note that
coercive elements within jail-based treatment programs can be re-traumatizing to
women. Others have observed that re-exposure to abusive behaviors can occur
withinaprisonsetting(Marcus-Mendoza,Klein-Saffran,&Lutze,1998),andmay
be associated with both violence and suicide attempts by incarcerated women
(Heney & Kristiansen, 1997). Resolution of these issues is important not only for
psychological well being, but also for the sustained sobriety of women in recovery
(Strauss & Falkin, 2000; Substance Abuse and Mental Health Services Adminis-
tration, 2000; Taylor, 1996). The elements of gender-sensitive approaches within
criminaljusticeenvironmentshavebeenhighlighted(Clark,2002;Hills,2003)and
include both training elements for corrections and treatment staff, and a careful
assessment of the manner in which security procedures are implemented, while
ensuring asafe environment.
Cultural Sensitivity
Women in county jails and state and federal prisons are predominantly women of
color (Greenfeld & Snell, 1999), who are disproportionately represented in drug-
relatedoffenses(Loper,2002).Thereisevidencethatincarcerationhasaparticularly
negative impact on women of color and that correctional policies contribute to
disparitiesinhealthbetweenwhitewomenandwomenofcolor(Freudenberg,2002).
Thishighlightstheneedforoffendertreatmentprogramstobeculturallysensitiveto
issuesofethnicityasaparticularaspectoffemaleoffendertreatmentneeds.
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456 J.Y.Sacks
Parenting
Approximately 70% ofwomenin federal andstate prisonsandjails andon parole/
probation haveminorchildren(underage18);thetotalnumberofminor children
for whom female offenders have some level of responsibility is estimated at
1.3 million (Greenfeld & Snell, 1999). Most of the women in prison were living
with their children prior to their arrest (Phillips & Harm, 1997), and retained
custodyoftheirchildrenpriortoincarceration(Colletal.,1997).Womeninprison
express feelings of guilt arising from their inability to provide for their children
properly, and many express fear about not knowing how to be a good parent
(American Correctional Association, 1990). Parenting education and activities to
strengthenthemother–childrelationshipandtoincreasecontactwithchildrenhave
been cited as important needs of incarcerated mothers (Lockwood et al., 1998).
Indeed, wardens from 35 women’s correctional facilities described childcare ar-
rangementsasa‘‘majorconcern’’oftheinmates(VanWormer&Schneider,2003).
Whileprisonsettingsdonotallowchildrentolivewiththeirmothers,parenting
education and activities that reinforce the mother–child relationship and increase
contactwithchildrenneedtobefacilitated(Lockwoodetal.,1998).Outcomedata
indicate that criminally involved women enrolled in drug treatment report less
parenting stress after completing a treatment program that includes parenting
education (Stevens, Murphy, &McGrath,2000).
Theintergenerationalimpactofparentalincarcerationandseparation,aswellas
parental substance abuse, mental illness, and victimization, cannot be overstated
(National Institute of Justice, 1998). Half of the children of incarcerated mothers
livewiththeirgrandparents,25%livewiththeirfatheroranotherrelative,and10%
live in a foster home or institution (Mumola, 2000). Maternal incarceration and
temporary placement of her minor children often make it difficult for female
offenderstoretaincustody(Hills,2003).Maintainingparentalrightsandachieving
family reunification challenges our capacity to provide inter-system coordination
amongcriminaljustice,substanceabuse,mentalhealth,andsocialserviceagencies.
Relationships with Significant Others
In addition to the treatment issues associated with substance abuse and/or mental
health disorders, gender-related needs of female offenders have included relation-
ships with significant others, health care, education, and employment (Alexander,
1996;Brunette&Dean,2002;Grella,2003;Hills,2003;Laudet,Magura,Vogel,&
Knight, 2000; Mueser& Fox, 2002).
Literature on women and addiction emphasizes the importance of relationships
as an organizing principle for their entry into drug use and crime and for their
recovery and abstinence from drugs (Covington, 1998; Hser, Anglin, & Booth,
1987; Reed & Leavitt, 1998). The social skills of women in the criminal justice
systemarepoorlydeveloped(Taylor,1996).Amongdrugusingwomenandfemale
offenders,intimatepartner,family,andsocialrelationshipsareoftenvolatile;three-
quarters of those with felony drug convictions report physical or sexual abuse by
husbands/boyfriends (Hirsch, 1999). Because women’s episodes of drug use, rela-
pse, and periods of abstinence are closely related to their significant opposite-sex
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Womenwithco-occurringdisorders:aresearchreview 457
relationships (Henderson, 1998), improving interpersonal skills and coping strate-
gies becomes particularly salient for substance abusing women (Lockwood et al.,
1998) and female offenders re-entering the community (Taylor, 1996).
Literacy, Education, and Employment
Basic education and literacy skills can be critical to success in the community, yet
female offenders have serious educational deficits, with over half lacking a high
school education (Hirsch, 1999; Stevens, Sechrest, & Patton, 1996), and most
describing poor job histories and limited work skills (Stevens & Patton, 1998;
Wexler, Cuadrado, & Stevens, 1998). Substance abusing women are more likely
thantheirmalecounterpartstobefinanciallydependentonafamilymember(Hser
et al., 1987), receiving public assistance (Harwood & McCliggott, 1998), and in
needofjobreadinessskills(Karuntzos,Caddell,&Dennis,1994).Withinaprison
setting, as Lockwood et al. (1998) noted, treatment providers are able to offer job
readiness training, a particularly important component of prison-based women’s
drug treatment programs(Centerfor Substance Abuse Treatment, 1999).
Health
The female offender’s history, lifestyle and drug use have multiple health-related
consequences(Young,1998).Substanceabuse,lifetimevictimization,andpsychia-
tric disorganization have each been associated with HIV-risk behaviors in female
offenders(Fogel&Belyea,1999;Huttonetal.,2001;Mullingsetal.,2003).Within
theprisonpopulation,34%ofwomenreporthavinginjecteddrugs,apracticethat,
when combined with risky sexual behaviors that are often part of the offender’s
lifestyle,causeswomentobetwiceaslikelyasmentobeHIVpositive(Henderson,
1998). Moreover, substance-abusing women often neglect their health so that
serious health problems (e.g. STDs, HBV, etc.) are undetected until they enter
the criminal justice system (Peugh & Belenko,1999; Stevens &Estrada, 1999).
IMPLICATIONS FOR TREATMENT SERVICES
WITHIN THE CRIMINAL JUSTICE SYSTEM
It is clear that women with COD constitute a special needs population in the
criminal justice system. The availability of programs for this population is increas-
ing,butseriousgapsinourunderstandingandtreatmentofwomenwithCOD,and
the complex of psychosocial problems affecting female offenders, remains. The
treatment needs of this population exceed the range of services provided through
traditional programming for offenders (Hills,2003; Mullings et al., 2003).
Overall Service Needs
The criminal justice system is in a unique position to assess COD and to provide
treatment to female offenders who might not otherwise have the opportunity to
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458 J.Y.Sacks
access such services. Although comprehensive identification of service needs is
importantforalloffenders,theassessmentofgender-specificneedsofwomeninthe
criminaljusticesystemiscriticalnotonlytotheirindividualsuccessbut,potentially,
to the success of their children as well. The system needs to use comprehensive
screeningandassessmenttoolstoimproveitscapacitytoidentifynotonlyCOD,but
alsotheissuesthathavebeendemonstratedasparticularlyrelevantinthehistoriesof
female offenders, including lifetime abuse and interpersonal violence, health risk
behaviors, parenting issues, and relationships with family and significant others.
Accurate evaluations will allow treatment programs to target content to the
identified needs of this complexand heterogeneous population.
Integrated Treatment
Withincommunity-basedtreatmentprograms,integrated,ratherthansequentialor
parallel, treatment programs have demonstrated effectiveness for individuals with
COD (Drake, Mueser, Clark, & Wallach, 1996; Minkoff, 2001). A recent
SAMHSA publication definesintegrated treatment as follows:
Integratedtreatmentrefersbroadlytoanymechanismbywhichtreatmentinterventions
for co-occurring disorders are combined within the context of a primary treatment
relationship or service setting. Integrated treatment is a means of actively combining
interventionsintendedtoaddresssubstanceuseandmentaldisordersinordertotreat
both disorders, related problems, and the whole person more effectively (Center for
SubstanceAbuseTreatment,inpress).
Investigators have reported that offenders with COD who are incarcerated in jails
(Munetzetal.,2001)orinprisons(Jordanetal.,1996)areappropriatecandidates
for integrated substance abuse and mental health treatment.
Few gender-specific, integrated, and comprehensive treatment programs for
women with COD exist in community based treatment and fewer still in the
criminaljusticesystem.Recently,diversionprogramsmaintainedthroughthecourts
(including drug courts, mental health courts, family drug courts, and domestic
violence courts) have begun to accept and address the particular problems of
individuals with COD (Peters & Osher, 2003). In a study of men and women
with COD in community-based residential drug treatment, only 24% had prior
‘‘dual diagnosis’’ treatment, even though 98% of the women had received prior
mentalhealthtreatmentand71%hadreceivedpriordrugtreatment(Grella,2003).
Thepresent author andcolleagueshavedescribed amodifiedtherapeutic commu-
nity(TC)programwithintegratedsubstanceandmentalhealthtreatmentformale
offenders with COD (Sacks, Sacks, & Stommel, 2003) and have demonstrated
significantreductionsinreincarcerationratesfortheexperimentalCODtreatment
group as compared to a mental health control group (Sacks, Sacks, McKendrick,
Banks, & Stommel, in press). There are few comparable treatment programs
specific to the needs and circumstancesof female offenders with COD.
Promising treatment practices need to be modified and refined for female
offenders with COD in a variety of criminal justice settings (e.g. prisons, jails,
diversion programs) and community treatment settings. Suggested modifications
include making programs more flexible and individualized, integrating substance
Copyright#2004JohnWiley&Sons,Ltd. Behav.Sci.Law22:449–466(2004)