Wallace, B.C., L.C. Conner, P. Dass-Brailsford (2011). Integrated trauma treatment in correctional health care and community-based treatment upon reentry. Journal of Correctional Health Care, 17(4):329-343.
By Lori Whitten, Staff Writer, RTI International, Rockville, MD
The majority of people in prison, particularly women, have a history of trauma—experiencing, witnessing, or being threatened with injury, serious harm, or death—stemming from violence, physical or sexual abuse, accidents, or disasters. For many, such traumas have been multiple and prolonged throughout life, and such experiences are intertwined with mental illness, substance abuse, and behavioral problems.
Responses to such events often result in the psychiatric disorder post-traumatic stress disorder (PTSD) or many of its symptoms—including having dreams and images of the trauma, experiencing distress at reminders of it, sleep difficulties, problems concentrating, hypervigilance, outbursts of anger, and avoidance of things associated with the trauma. Incarceration may worsen these symptoms, or in some cases induce them, impeding adjustment to prison or community re-entry.
Despite the high prevalence of trauma among incarcerated people and its negative impact upon them, researchers have only recently turned attention to addressing this mental health problem among prisoners. Barbara C. Wallace, Ph.D., and colleagues at Columbia University in New York City summarize the issue of trauma among incarcerated people, discuss its high prevalence and mental health consequences, and identify evidence-based and promising treatment approaches. These researchers suggest points to help practitioners and policy makers integrate therapy for trauma and improve service delivery to inmates in correctional facilities and former prisoners in community-based treatment programs.
The high prevalence of trauma among prisoners appears to be most critical for women. Although many male offenders have experienced trauma, an estimated 77 to 90 percent of women with drug dependency in prison report extensive histories of emotional, physical, and sexual abuse. Wallace and colleagues say that the high lifetime prevalence of victimization among women prisoners indicates a need to formally assess this problem, intervene to reduce the risk of further trauma during incarceration, and provide gender-sensitive and trauma-informed treatment.
Women who have experienced abuse may not feel comfortable with male counselors or peers in group therapy, and therefore may respond better to gender-sensitive treatment that recognizes their unique problems and is provided exclusively by females. Among women who have experienced extensive abuse, co-occurring mental illness, particularly PTSD and substance abuse, are common, and trauma-informed treatment acknowledges this. Integrated treatment addresses trauma and substance abuse simultaneously rather than requiring abstinence first—which has been a common practice among therapists. Wallace and colleagues note that trauma-informed and integrated treatment overlap in some areas, and they cite research on such therapeutic approaches (see table).
For prisoners who are re-entering the community, providers may select from a menu of evidence-based and promising treatments that address co-occurring trauma, mental illness, substance abuse, and behavioral problems. These include cognitive-behavioral therapy, relapse prevention, social skills training, motivational interviewing, 12-step facilitation, individualized drug counseling, community-reinforcement approach plus vouchers, and contingency management. Because offenders are a diverse population, Wallace and colleagues suggest that practitioners work with people in therapy to tailor integrated treatments that best meet each person’s unique needs. Practitioner and staff training in this treatment approach would increase the likelihood that the services provided will be evidence-based, culturally appropriate, and gender-sensitive.
Evidence-Based and Promising Treatments for Women Who Have Experienced Trauma
Various treatments address trauma, mental illness, and substance abuse—problems that frequently co-occur among women in prison.
More General Applicability
Addiction and Trauma Recovery Integration Model (ATRIUM)
Integrates cognitive-behavioral therapy and relational treatment; focuses on mental, physical, and spiritual health; group therapy; 12-week curriculum.
Developed for women, but limited use in mixed-sex treatment groups.
Seeking Safety (SS)
Cognitive-behavioral approach; promotes safety and encourages control over substance use; group therapy; covers 25 topics.
Efficacy for males and females; used in inpatient, outpatient, and residential treatment, as well as correctional facilities, mental
health centers, and individual counseling sessions.
Trauma Recovery and Empowerment Model (TREM)
skills training, and psychoeducational techniques; focuses on trauma experience,
empowerment, and skills building; group therapy.
Adapted for mental health, substance abuse, and criminal justice settings.
Collaborative approach among community treatment providers, researchers, and clients to shape services; promotes survival, recovery, and empowerment; group therapy; 16-week curriculum.
Used in jails, homeless shelters, and domestic violence centers as well as in outpatient or residential community mental health centers, and substance abuse treatment facilities; with modifications, used in correctional settings.
Helping Women Recover (HWR)
Focuses on self, relationships, sexuality, and spirituality; uses expressive arts, relational theory, and cognitive-behavioral interventions; group therapy; 17-week format.
Used in residential and outpatient settings; adapted for use in the criminal justice system, including juvenile settings.
Trauma Affect Regulation: Guidelines for Education and Therapy (TARGET)
For adolescents; develops self-and emotional-regulation; cognitive-behavioral intervention; teaches a simple sequence of practical skills to cope with stress, substance use problems, and PTSD symptoms; group therapy.
For male and female adolescents; used in correctional and reentry settings.
For more information contact Dr. Barbara C. Wallace of the Department of Health and Behavior Studies, Teachers College, Columbia University, in New York, New York, Wallace@tc.columbia.edu
Points of view or opinions stated in this blog are those of the authors and
do not necessarily represent the official position or policies of
the U.S. Department of Justice.