Pregnant, Substance-Abusing, and Incarcerated: Exploratory Study of a Comprehensive Approach to Treatment

Kubiak, Sheryl Pimlott

ABSTRACT

Interventions addressing the multiple needs of incarcerated women are rare. In this study, several measures were used to assess functional changes among pregnant, substance-dependent, incarcerated women transferred to a community-based residential treatment program that allowed their infants to reside with them. Women engaged in comprehensive therapeutic and skill-building activities for 6 to 9 months. The program's goal was to assist women in childbirth and in the continuing relationship with their child while improving psychological and social functioning. Examination of changes were limited to those who completed treatment and all measures (n = 27). Although significant improvements were noted, nearly half were discharged with symptoms indicative of a depressive disorder. Assessment of long-term outcomes comparing this group with pregnant women who remained in prison is under way.

Although women represent less than 10% of those incarcerated in the United States, pregnancy and childbirth during confinement pose special challenges, especially for the mother-child dyad. Most states transport the woman to a local hospital for delivery and then return her to the institution within 24 to 48 hr-without the infant. Women and Infants at Risk (WIAR) is an alternative-sentencing, community-based, residential program that allows pregnant women to transfer from prison in order to reside with their infants after delivery and participate in their own treatment, education, employment assistance, and parenting enhancement for approximately 6 months. The goals of the program are to assist women in continuing their relationship with the child as they integrate back into the community by improving psychological and social functioning so that women remain drug free, gainfully employed, and out of criminal justice custody.

To accomplish such goals, a multifaceted and comprehensive program was developed and implemented by a collaborative community group, consistent with guidelines set forth by the Center for Substance Abuse Treatment (CSAT; 1994). Comprehensive approaches recognize that the presenting problem of addiction is usually complicated by concerns in other life domains, such as employment, housing, and family relationships (Covington, 1999). Advocates of this type of approach contend that simply treating the addiction results in ineffective solutions that are disrespectful of the individual's complexity and are often short lived (Finkelstein, 1994; Zelvin, 1999). Moreover, evaluations of such programs must measure change across multiple domains. Therefore, in this article, we describe outcomes in two domains, social and psychological functioning, as part of the evaluation of a unique intervention for pregnant female offenders.

Background

The rapid growth of the number of women in the criminal justice system over the last 15 years, exceeding the growth rate of men in the system, can be largely attributed to drug involvement because most women have either been convicted of a drug offense or were using drugs at the time of arrest (Beck, 2000). Women offenders are typically poor, uneducated, and limited in job skills; more than half are unemployed before their incarceration (Pimlott & Sarri, 2002; Siefert & Pimlott, 2001). As a result of poverty, selective arrest, prosecution by race, and lack of access to legal resources, women of color are disproportionately represented among women offenders (Pimlott & Sarri, 2002; Siefert & Pimlott, 2001). In addition, minority women have experienced a greater proportion of convictions under the enhanced felony drug laws than any other group (Mauer & Huling, 1995; Mauer, Potler, & Wolf, 1999). Most women offenders have been medically uninsured or underinsured before incarceration, and lack of adequate health insurance is a major reason for their inability to obtain treatment for drug dependence (Barry, Ginchild, & Lee, 1995).

In addition, most women interfacing with the criminal justice system are mothers. It is estimated that 75% to 80% of women in jails and prison are mothers (Ascione & Dixson, 2002; Bloom, 1995; Johnston, 1995b) and that parental crime, arrest, or incarceration interferes with their children's development and predicts intergenerational incarceration (Johnston, 1995a). Moreover, as many as 25% of female offenders are pregnant at prison intake or have delivered within the past year (Siefert & Pimlott, 2001; Wooldredge & Masters, 1993). Infants of inmates who deliver in prison are typically separated from their mothers following delivery and placed in relative or foster care until completion of the mother's sentence. This separation interferes with mother-infant attachment and can result in adverse developmental consequences for the child as well as psychological distress for the mother (Wooldredge &Masters, 1993).

Nearly a third of all incarcerated women are convicted of a felony drug offense, but drug use among female offenders is far greater than the numbers who are actually convicted of drug offenses. Although the treatment needs of substance-abusing women have been well documented (Boyd, 1993; Boyd, Hill, Holmes, & Purnell, 1998; Kilpatrick, Resnick, Saunders, & Best, 1998; Root, 1989; Weaver, Turner, & O'Dell, 2000; Wilsnack & Wilsnack, 1990), women involved in the criminal justice system have more complex needs and immediate demands (Covington, 1999; El-Bassel, Gilbert, Schilling, Ivanoff, & Borne, 1996; Gilfus, 1992; Henderson, 1998; Richie & Johnsen, 1996; Sanders, McNeill, Rienzi, & DeLouth, 1997; Wellisch, Prendergast, & Anglin, 1994). For example, they must meet court and sentencing requirements as well as circumvent the emotional (e.g., shame) and logistical (e.g., employment) obstacles related to the stigma associated with conviction. Women offenders are likely to face employment discrimination and loss of public aid as a result of their conviction status (Allard, 2002; Hirsch, 2001; Kubiak, 2004).

Incarcerated women also have been identified as being at risk because of physical and mental health problems (Acoca, 1998; Ingram-Fogel, 1991; Jordan, Schlenger, Fairbank, & Caddell, 1996; Teplin, Abram, & McClelland, 1996). Rates of depression among incarcerated women were nearly twice the rate of the community comparison, and the odds of their having a drug or alcohol disorder were between 15 and 46 times greater than in the community comparison group (Jordan et al., 1996). Furthermore, the increased exposure to traumatic incidents among offending women has been well-documented (Covington, 1999; Henderson, 1998; Richie & Johnsen, 1996).

In their national review of treatment for drug-abusing women offenders, Wellisch, Prendergast, and Anglin (1994) found that most programs do not assess the multiple problems presented by the women and fail to provide them with appropriate services. They recommend that programs assist women in the transition from treatment to independent living in the community by including vocational training, family services, and programs that provide accommodations for infants and children.

Treatment Effectiveness

Although comprehensive approaches to treatment consider abstinence or decreased use a positive indicator of effectiveness, other measures of social and psychological well-being are also important. Because treatment-seeking women who are in conflict with the law are more likely to need comprehensive supports than other offending women (Alemagno, 2001), functional assessments of social well-being can also measure program effectiveness. Similarly, psychological well-being can be linked to the individual's belief in her own capacity to exercise control over a given event and the environment in general (Bandura, 1977, 1999), as well as the absence or improvement of mental health disorders. Certainly, drug and alcohol abuse recovery are likely to be short lived without attention to the multidimensional needs of these women (Alemagno, 2001; Henderson, 1998; Richie & Johnsen, 1996).

In the present study, our purpose was to test the efficacy of this treatment model by examining changes in incarcerated women's social and psychological well-being over the course of residential treatment. We expected that the comprehensive nature of the program would enhance skills related to employment and community living, while simultaneously improving feelings of individual mastery and decreasing depression. In addition, we were interested in the effect of trauma exposure on these outcomes and predicted that the presence of symptoms associated with a stress disorder would negatively affect psychological and social functioning.

Method

Program

Pregnant women who had a history of drug or alcohol dependence and who were entering the state or local corrections system with a nonassaultive offense were eligible for participation. In addition, women had to be willing to actively parent their infants and remain in the program at least 4 months following the infants' birth, regardless of the duration of their sentence. Once eligibility was established, the pregnant prisoner was transported from the institution to the community-based residential program. Women attended educational classes and employment preparation and had the option to enroll in vocational programs. Later they were assisted with job searches and required to work full-time for 30 days prior to discharge. Other services included substance abuse education, group and individual therapy, drug testing, family counseling, day care, and weekend overnight visits with their other children. Discharge planning focused on securing housing and coordinating aftercare services, such as pediatric visits, ongoing treatment, support groups, and day care (see Siefert & Pimlott, 2001, for full details).

Procedures

A program representative, prison classification personnel, and a nurse midwife screened the women for eligibility. Once eligibility was determined and the transfer date was secured, evaluation staff members were notified. A member of the evaluation team met with each woman within 1 week of program entrance and invited her to participate in the program assessment. As an incentive for involvement, women were given a video of mother and baby and a gift certificate to a local department store.

Interviews were conducted at three points in time: within 1 week of program admission (Time 1: admission), 1 month postdelivery (Time 2: postnatal), and at 4 months postdelivery and prior to discharge (Time 3: discharge). A similar set of instruments was given at all three time points, in addition to open-ended questions of the women's perceptions of the program and their progress. Attempts were made to retain the same interviewer through all three sessions. In addition to instruments and interviews, program documentation on drug screens, employment verification, and medical data was collected by evaluation staff (see Seifert & Pimlott, 2001; Barkauskas, Kane-Low, & Pimlott, 2002).

Measures of Social Well-Being

Objectives pertaining to social well-being were monitored over the course of treatment and include life skills related to community living, employment-seeking skills, and program completion status. Thus, in addition to measuring client retentions, we measured the extent to which clients acquired the specific skills needed to function effectively in the community and to meet other goals such as securing employment and housing.

Successful completion. Successful program completion was determined by meeting all of the following objectives: (a) completion of all four treatment phases, (b) infant a minimum of 4 months old, (c) mother employed for all 4 weeks prior to discharge, and (d) completion of a comprehensive aftercare plan. Although abstinence was not a condition of completion, women had to be drug free for a minimum of 30 days prior to discharge. This gave the relapsing client time to rework her relapse prevention plan and receive intensive services from staff. The exception to this was that any positive drug screens during pregnancy were cause for immediate termination.

Community Life Skills Scale. To examine WIAR's effect on enhancement of life skills, we administered 14 selected items from the Community Life Skills Scale (CLSS), part of the Nursing Child Assessment Satellite Training Program (Barnard et al., 1988). The 14 items chosen from the original 32 CLSS items were those most relevant to the woman's current circumstances (in residential treatment) and covered skills in the domains of budgeting, transportation, and support services. (Note: Discarded items pertained to independent-living behaviors, such as grocery shopping.) The women were instructed to indicate how they "deal with the practical things that are part of keeping a job and a place to live" with either a yes or no. Items were summed to provide an overall skills score. Previous research has shown that the CLSS has high predictive validity: Mothers who perform well on the CLSS are less likely to drop out of a parenting treatment program (Barnard et al., 1988) and are more likely to have positive mother-child interactions; their children are also more likely to have favorable developmental outcomes (Booth, Mitchell, Barnard, & Spieker, 1989).

Job Search Self-Efficacy Scale. To measure the program's impact on women's acquisition of the skills needed to find a job, we administered the Job Search Self-Efficacy Scale (JSSES; Van Ryan & Amiram, 1992), which measures respondents' confidence in their competence at various tasks associated with the job search. Respondents are asked to indicate how well they are able to do various tasks related to being able to look for and find a job using a 5-point scale ranging from not well at all to quite well. Items were summed to provide an overall efficacy scale. The JSSES was found to be positively related to participation in an intervention program that was effective in promoting successful job search behavior and employment (Van Ryan & Amiram, 1992). Reliability on the JSSES has been reported at .85 (Wanberg, Watt, & Rumsey, 1996) and was .88 in this sample at admission and .82 at exit.

Measures of Psychological Well-Being

Psychological well-being was assessed in two domains: changes in depressive symptoms and an increase or decrease in a personal sense of mastery.

Depression. The Centers for Epidemiological Studies-Depression Scale (CES-D; Radloff, 1977) is a widely used self-report and screening measure that provides an index of the number and frequency of depressive symptoms. Respondents were asked to use a 4-point scale to indicate how often during the past week they felt or behaved each of 20 ways. Items included statements such as, "My sleep was restless," "I had crying spells," and "I could not get going." There were 16 negative-affect items and 4 positive-affect items, which were reversed scored ("I enjoyed life") to yield a single, summed score for depression. The alpha coefficients measuring the internal consistency of the CES-D ranged from .84 to .90 on the four samples used in the validation studies (Radloff, 1977). Radloff (1977) reported test-retest correlations of .51 at 2 weeks, .67 at 4 weeks, .59 at 6 weeks, and .59 at 8 weeks.

Mastery. Mastery was assessed using Pearlin and Schooler's (1978) Self Mastery Scale (SMS), which measures the extent to which respondents regard personal life experiences as being under their own control in contrast to being fatalistically ruled. Respondents are asked to indicate the extent to which they agree or disagree with seven statements using a 7-point scale. Items were summed to provide an overall mastery scale. The psychometric properties for internal consistency were reported by Cozzarelli (1993) with an alpha coefficient of .77. Cozzarelli found the SMS to be highly correlated with the Rosenberg Self-Esteem Scale, the Life Orientation Test (a measure of optimism), and negatively correlated with the CES-D. Internal consistency in this group was .54.

Trauma and posttraumatic stress disorder (PTSD). The Trauma Screening Questionnaire (TSQ) assesses life-threatening events and was based on the PTSD module of the University of Michigan version of the Composite International Diagnostic Interview (UM-CIDI; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995), but it was developed specifically for use with low-income women (Green, Saigh, & Korol, 1996). Green et al. (1996) modified the original 11-item UM-CIDI by adding questions on childhood abuse and domestic violence as well as by expanding the questions on rape and molestation to be more behaviorally specific. The TSQ begins by asking respondents about whether they were exposed to a trauma, and if so, when it occurred. A decision was made to modify the more intrusive elements asking women who were looking at a list of the possible events-"How many different types of events have you ever experienced over your lifetime." This decision was an effort to reduce the possibility of triggering past events, and perhaps a drug relapse. The second part of the TSQ used the Diagnostic Interview Schedule to determine whether the current symptoms would meet criteria for PTSD diagnosis. This abbreviated screening was not intended to be a clinical diagnosis, only to determine exposure history and current symptoms that may be trauma related.

Analysis

Descriptive statistics and paired t tests were used to examine women's behavioral objectives (life skills, employment skills, and program completion). To test the null hypothesis of no change over time in measures of psychological well-being (i.e., depression and mastery), we conducted paired t tests or repeated measures analyses of variance (ANOVAs). Repeated measures ANOVA is a within-subject design that uses individuals as their own control in order to measure change. In each of these withinsubject analyses, we used contrasts to determine whether change occurred overall, and if so, when (i.e., between Time 1 and Time 2; between Time 2 and Time 3; or between Time 1 and Time 3). Using contrasts, we were able to isolate the time period that was most important for each variable, as well as the direction of change.

Results

Participation

Between July 1996 and December 1998, 52 pregnant women were admitted to the WIAR program directly from prison or jail. Of those 52, subgroups of women who completed the program (n = 34) and those who completed and participated in the evaluation at all three time points (n = 27) are highlighted in the present study. First, Table 1 provides demographics on the entrance sample (n = 52); it also allows one to compare demographics on those who successfully completed the program (n = 34) with those who did not (n = 18).

In the overall sample, the women ranged in age from 19 to 42 years with a mean age of 28.50 (SD = 5.46). The majority of women did not complete high school (75%) and had a mean educational level of 10th grade. Regarding ethnicity, 65% were African American and 35% European American, and although only one woman was married, 45% claimed the presence and/or support of a significant other. The mean number of children among the women was 2.38 (SD = 2.00); however, for 12% of the women, this pregnancy was their first child. Half the women (50%) had one or two other children, a third (34%) had three or four children, and 14% had five or more children. Those with other children had caregiving arrangements with the children's maternal grandmothers (32%), other family members (19%), fathers (11%), foster care (8%), or a combination of providers (30%).

Nearly half of the women (48%) were incarcerated for property-related offenses, such as retail fraud and forgery, and 40% were convicted of felony drug offenses. The remaining women were charged with other offenses or violations of parole or probation (12%). Even though 40% of the women were convicted of a drug-related crime, 65% stated that drugs were involved in their offense (e.g., they were under the influence during the offense). During clinical interviews with trained clinicians, all women met drug and/or alcohol dependency criteria as specified in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994). The majority (52%) claimed cocaine as their primary drug of choice, followed by marijuana (24%), alcohol (22%), and heroin (3%).

Although a more thorough assessment of program completors versus noncompletors follows, an analysis of possible differences revealed that women who completed were more likely to be White with a higher educational attainment.

Outcomes

Outcome measurement was along two domains, social and psychological functioning, although we used multiple constructs in each domain. For example, depression, mastery, and trauma exposure were all separate indicators of the single construct of psychological well-being. Similarly, attainment of life and employment skills were separate indicators of social functioning. As with most constructs, there are various approaches to measurement, and relationships may exist among these indicators. Examples of the intercorrelations between all of these constructs are shown in Table 2.

Assessment of social well-being outcomes. As stated previously, of the 52 women who entered the program during the study period, 34 women (65%) met all the criteria for successful discharge. Of the remaining 18 women, 9 left the program on escape status, 6 were terminated by staff for noncompliance with program rules (e.g., positive drug screens), and 3 women were released from the program when they no longer met eligibility criteria because of the loss of the infant through miscarriage or because of the infant's removal by protective services. Overall, the mean length of stay was 7.5 months and ranged from 1 day to 14 months. Criminal justice status at admission was an important variable that differentiated completors from noncompletors: Women sentenced to the program directly from the courts were more likely to leave on escape status than those who entered after some period of incarceration.

Of the 34 who successfully graduated, an assessment over time of 27 demonstrates that those completing the program made substantial gains in functional objectives associated with life skills and employment search efficacy. Table 3 illustrates the acquisition of community life skills-for individual behaviors and overall. For example, although only 64% knew how to budget at the time they entered the program, all participants reported the ability to do so upon exit. Similarly, although only 25% had a bank account at the time of program entry, 67% had an account upon exit.

Table 4 presents clients' assessment of their ability to effectively perform job-seeking tasks prior to entering the program and at exit. Clients reported improvement in their ability to prepare a resume, contact an employment agency, and obtain a job interview. Finally, overall efficacy in employment-seeking behaviors improved significantly over the course of the program: 3.86 at admission compared with 4.54 at discharge, t(26) = 3.62, p = .001. In addition, all women were employed (often for the first time) at exit.

Psychological changes in well-being. Outcomes were also assessed in psychological well-being over the course of the program. Scores on the CES-D and SMS were compared at admission, at 1 month following delivery, and at discharge, whereas traumatic exposure and symptoms of PTSD were assessed at admission. Depressive symptoms decreased during the course of treatment; overall, symptoms averaged 18.3 (SD = 11.0) at admission, peaked postnatally to 20.2 (SD = 11.3), and decreased to 14.2 (SD = 11.8) at discharge. Using repeated measures ANOVAs and planned contrasts on those with all three data waves (n = 27), we found that the change in depression between program admission and program discharge was marginally significant, F(1, 26) = 3.95, p = .058. However, the time period between postnatal and discharge indicated a statistically significant improvement in depression, F(1, 24) = 7.90, p = .01.

Although depression decreased over the duration of the program, further investigation of depression at Time 3 revealed that nearly half the group (M = 45.2) had clinical symptoms of depression at discharge (i.e., CES-D over 16). In fact, almost 40% (38.7%) had symptoms indicative of severe depression (i.e., 23 or above on the CES-D).

An examination of mastery between admission and discharge indicated significant improvement over time, t(26) = 2.12, p = .04. This suggests that women felt more control over their environments when they left the program than when they entered. However, mastery correlated with depression (Table 2), so an assessment on the effect of depression on mastery found that those with higher depressive symptoms (either at admission or discharge) were significantly less likely to feel efficacious at discharge. For those who had CES-D scores of 16 or greater (possible depression) at admission, mastery was significantly lower at discharge: 5.40 versus 6.34, t(24) = 2.92, p = .008. Similarly, for those with symptoms of a possible depression at discharge, mastery at exit remained low as well: 4.90 versus 6.22, t(29) = 5.41, p = .0001.

In an attempt to understand this high level of depressive symptoms, we examined the possible effect of traumatic exposure and/or meeting symptom criteria for PTSD. Although the correlation between the number of events and depressive symptoms was not significant (see Table 2), we found that those with a possible depression at exit were more likely to meet criteria for PTSD than those without a possible depression: 66.7% versus 33.3%, [chi]^sup 2^(1, N = 26) = 5.23, p = .02.

Overall, outcomes indicate that for those who completed the program, there was an improvement in social well-being demonstrated through skill development and positive changes in psychological well-being. Although these data suggest an overall decline in depressive symptoms over the course of treatment, nearly half maintained serious levels of depressive symptomatology, which is correlated to their feeling of efficacy and may be related to previous trauma exposure.

Discussion

In this study, we documented the treatment needs of pregnant, substance-abusing women involved in the criminal justice system and examined short-term outcomes following a comprehensive treatment approach, particularly in the domains of social and psychological well-being. The findings suggest that such approaches are efficacious in producing positive gains over the course of treatment for those who completed it.

Although improvements were noted between admission and discharge, only 65% (n = 34) of those admitted completed treatment. In other words, for approximately one third of the women who entered, attainment of completion goals, such as maintaining contact with and custody of the infant, securing employment, and creating supportive linkages in the community, were not met. More importantly, completion also increased the length of time in treatment, and numerous studies have documented the relationship between treatment longevity and reductions in drug use and criminal behavior (Pearson & Lipton, 1999; Wexler, Falkin, & Lipton, 1990). Because WIAR is a long-term residential program, successful completion demands a minimum stay of 6 months but averaged 7.5 months for those completing all the requirements. At this time we cannot assess the program's effect on those women who did not complete it, but we hope to in future research.

However, an examination of treatment failures provides valuable information for improving program services. For example, criminal justice status was highly predictive of completion status. In fact, nearly half (44%) of the women who were unsuccessful and only 12% of those who were successful were on probation status, [chi]^sup 2^(1, N = 52) = 6.19, p = .01. Although the facility is secure (24-hr staffing and alarmed doors, etc.), it is not a locked institution with armed guards. Some women left within 24 hr of admission, using the treatment program as an early release avenue.

There is some question as to whether women admitted directly from the courts on probation status were less motivated or had less severe substance abuse histories than women who entered directly from the secure environment of the state prison. Although preadmission screening may be able to ascertain differences in substance abuse severity (all women who entered were considered drug or alcohol dependent), it did not assess motivation or treatment readiness. It is possible that women entering directly from prison experienced a longer "dry out" or detoxification period than women entering from the court of sentencing or coming from short-term jail stays, and thus the former experienced less physiological and/or psychological craving.

Berkowitz, Brindis, Clayson, and Peterson (1996) documented similar findings between mandated and nonmandated treatment participants, noting that those mandated through criminal justice agencies were more likely to complete than those who entered voluntarily. As they are careful to note, this does not imply that coercion is the most effective motivation. Determinants to treatment entry as well as completion are complex and include substance use duration and intensity as well as family, economic, and personal factors. Therefore, all of these factors need to be considered when making decisions regarding who is motivated for treatment.

In addition, 2 women were terminated for drug use during their pregnancy and returned to prison. Although the program is more tolerant of relapse during the postnatal period, the initial agreement with the corrections department was zero tolerance for use during pregnancy. Moreover, 2 women had positive drug screens during the postnatal period and were retained in treatment (with a loss of house privileges as a sanction) and graduated successfully.

Assessment of community life skills demonstrated that many women were lacking in the ability to navigate systems necessary for sustenance of themselves and their child, but they successfully obtained these skills during the treatment course. In addition, even though few women gained vocational expertise, efficacy in searching and acquiring employment improved over the course of treatment. Obtaining employment is critical to the long-term success of treatment for substance-abusing women and is particularly important given welfare reform's emphasis on requiring work as a condition of welfare receipt for single mothers, as well as time limits and sanctions for those who do not find and maintain employment.

Overall, women who entered the program demonstrated significant improvements in levels of depressive symptomatology and feelings of individual mastery. Depression symptoms declined significantly between program admission and discharge; however, the number of women discharged with depressive symptoms in the severe range was a serious concern.

Severe depression at program exit for this group may be reflective of the recognition of imminent difficulties they face in the reintegration process back into the community, where they have enhanced responsibilities and limited resources. In a sample of current and recent welfare recipients transitioning from welfare to work, Siefert, Bowman, Heflin, Danziger, and Williams (2000) found a significant association between cumulative environmental risk factors and increased risk of major maternal depression. These risk factors (e.g., poverty, hazardous neighborhoods, stressful living situations, etc.) were similar to those many of the WIAR participants encounter and are conditions the program has little ability to affect.

Similarly, women with symptoms indicative of PTSD at admission experienced more traumatic events over their life course and experienced higher depression levels throughout the program. Interestingly, trauma exposure was also linked to community life skills; those with more trauma demonstrated a lower ability to navigate or manage life tasks such as transportation, budgets, and scheduling. Other research has demonstrated greater mental health sequelae with increased trauma exposure (Breslau, Chilcoat, Kessler, & Davis, 1999; Kassler et al., 1995; Perkonigg, Kessler, Storz, & Wittchen, 2000; Pimlott-Kubiak & Cortina, 2003) and the need for integrated treatment of co-occurring substance use disorders and PTSD (Najavits, Weiss, & Shaw, 1998). Replication of this type of program would be well advised to include such a treatment modality.

The program's strategy of comprehensive discharge planning may provide some relief and assistance to the women. Women remaining in the geographic area were encouraged to continue treatment at the agency and to bring their infant with them. Similarly, they continued to receive health care from the same providers. Those women who moved elsewhere in the state had to have follow-up appointments with both health care and substance abuse treatment professionals before discharge. Unfortunately, at the time of this study, state policy did not allow those on inmate status to receive any psychotropic medications, limiting treatment options for these women.

Limitations

It should be noted that the findings of this study are limited by several factors: a large number of statistical comparisons relative to the small sample size, variation in sample size over the course of the program because of either attrition or refusal to participate in the assessment at one or more intervals, variables that were intercorrelated, and the use of self-report measures versus clinical interviews. Although a comparison group of women who remained in prison during their pregnancy-and returned there without the child after the birth-was developed, outcomes were not treatment related but were based on long-term recidivism, relapse, and custody of the child. This comparison study is forthcoming, and so we will wait to draw definitive conclusions.

Conclusion

Treatment interventions that enhance psychological well-being may be beneficial, but they alone do little to change the social and political context the women find themselves in. This is especially true when previous environments have involved traumatic life experiences. Many women return to severe poverty, inadequate housing, limited support programs (such as Temporary Assistance to Needy Families), and an employment market that is uninterested in or hostile to those with felony convictions. In addition, changes in criminal justice policies around the country have limited the feasibility for this type of program. In particular, truth in sentencing legislation (see Ditton & Wilson, 1999) negates the use of early release into the community as it mandates that the offender serve the complete minimum sentence in a locked facility. All of the women who entered this program from prison did so on early release, and it is unlikely that childbirth would have waited.

Perhaps more importantly, the number of women entering the criminal justice system continues to escalate. Although this study focuses primarily on those sent to prison, the far greater number are those on probation sentences living in the community (see Kubiak, 2004). This is a group that is in need of prevention services to keep them out of confined settings. Although probation may yield a second chance to stay in the community versus confinement, lack of services and supports during that period may result in probation failure and subsequent incarceration. However, health care workers in the community can work collaboratively in preventing such incarceration by providing a network of services and support for these women and their children. Such services may include supported employment, child care, integrated substance abuse and mental health treatment, and a strong relationship with the court.

Successful coping is dependent upon individuals' belief in their ability to master their environment (Bandura, 1977). Although the program was apparently successful in enhancing the women's sense of mastery and improving their life skills, it is unclear how high an individual's sense of mastery needs to be in order to effectively cope with the multiple hardships these women encounter.

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Sheryl Pimlott Kubiak, PhD, is assistant professor of social work at Wayne State University, Detroit, Michigan and is the former and founding director of the program evaluated in this article. This research was conducted while she was at the Institute for Research on Women and Gender, University of Michigan, Ann Arbor, Michigan. Amy Young, PhD, is research scientist at the University of Michigan Substance Abuse Research Center. Kristine Siefert, PhD, is professor, School of Social Work, University of Michigan, and is associate director, National Institutes of Mental Health Research Center on Poverty, Risk, and Mental Health. Abigail Stewart, PhD, is professor in the Departments of Psychology and Women's Studies, University of Michigan. Correspondence regarding this article can be addressed to the first author at spk@wayne.edu or Wayne State University, Thompson Home, Detroit, MI, 48202.

Authors' note. This work was supported in part by a grant from the Skillman Foundation.

Manuscript received: July 11, 2003

Accepted: March 11, 2004

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