2311345

Behavioral Sciences and the Law
Behav. Sci. Law 26: 413–434 (2008)
Published online in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/bsl.828
Treatment Outcomes for
Female Offenders: Relationship
to Number of Axis I Diagnoses
Joann Y. Sacks, Ph.D.,*,y
Karen McKendrick, M.P.H.,z
Zachary Hamilton, M.A.,x {
Charles M. Cleland, Ph.D.,
jj
Frank S. Pearson, Ph.D.
and Steven Banks, Ph.D.#
This article describes a study that examined the relationship between multiple Axis I mental health diagnoses and
treatment outcomes for female offenders in prison substance abuse treatment programs. Preliminary findings of
the effectiveness of therapeutic community (TC) treatment, modified for female offenders, relative to a control
cognitive behavioral treatment condition, are presented.
The hypothesis—that participants who fit into multiple
diagnostic categories have more dysfunctional symptoms
and behaviors at baseline—was confirmed; however, a
hypothesized relationship between the number of Axis I
diagnoses and 6 month treatment outcomes across five
domains (mental health, trauma exposure, substance
use, HIV needle risk behaviors, and HIV sexual risk) was
not supported. Across all Axis I mental health groups, TC
treatment was significantly more effective than the control
condition overall, as well as on measures of mental health
symptoms and HIV sexual risk. These findings suggest that
this TC treatment program, as modified, is an effective
model for women with varied diagnoses and diagnostic
complexities. Copyright # 2008 John Wiley & Sons, Ltd.
*Correspondence to: Joann Y. Sacks, Ph.D., Center for the Integration of Research and Practice (CIRP),
National Development and Research Institutes, Inc. (NDRI), 71 West 23rd Street, 8th Floor, New York,
NY 10010, U.S.A. E-mail: [email protected]
y
Deputy Director.
z
Assistant Project Director, Center for the Integration of Research and Practice (CIRP).
x
Research Associate, Center for the Integration of Research and Practice (CIRP).
ô
Statistician, Center for the Integration of Research and Practice (CIRP).
k
Senior Principal Investigator, Center for the Integration of Research and Practice (CIRP).
#
Research Associate Professor of Psychiatry, University of Massachusetts Medical School.
Copyright # 2008 John Wiley & Sons, Ltd.
414
J. Y. Sacks et al.
BACKGROUND
Co-occurring Disorders and their Relationship to Crime and
Incarceration
It is well documented that individuals with co-occurring substance use and mental
disorders have a greater propensity to be involved with the criminal justice system,
and hence are more likely to become incarcerated (Drake, Xie, McHugo, &
Shumway, 2001; James & Glaze, 2006; McNeil, Binder, & Robinson, 2005;
Monahan et al., 2001, 2005; Regier et al., 1990; Sacks, Sacks, De Leon, Bernhardt,
& Staines, 1997) and tend to re-enter the correctional system once released to the
community (Messina, Burdon, Hagopian, & Prendergast, 2004; Peters, LeVasseur,
& Chandler, 2004). Among a community-based sample of individuals with cooccurring drug abuse and mental illness, Sacks and colleagues (1997) found that
nearly all participants (99%) had some criminal involvement, with 86% having at
least one arrest and 59% having at least one conviction, and on average 4.1 years of
prior incarceration[s].
The provision of required treatment services to incarcerated individuals with cooccurring disorders represents a substantial challenge to treatment and correctional
systems (Kubiak, 2004; Sacks, Sacks, McKendrick, Banks, & Stommel, 2004a).
In a previous analysis, Sacks and colleagues (2008) described such an offender
population, revealing several deficit/need areas related to employment, education,
residential stability, and criminality, in addition to services related to psychological
symptoms and substance use. Correctional treatment programs often lack the
resources required to address this complexity of offender needs adequately; in the
absence of such treatment and post-prison community supports, offenders with cooccurring disorders are more likely to be reincarcerated than those with substance
use problems alone (Messina et al., 2004).
Gender, Co-occurring Disorders, and Offenders
The prevalence of behavioral health disorders differs by gender both for the general
population and within the criminal justice system. Robins and Regier (1991)
estimated that approximately 20% of men and women in the general population had
an active disorder; however, men experienced higher rates of antisocial personality
disorder and substance abuse disorders compared with women, who were more
likely to have mood disorders, including depression, generalized anxiety, panic,
phobia, and somatic disorders. This pattern is especially evident for substanceabusing men and women. Compared with their male counterparts, substanceabusing women were almost four times more likely to have major depression with
co-occurring alcohol abuse, three and a half times more likely to have co-occurring
panic disorder, and more than twice as likely to have phobic disorder (Blume, 1990).
Rates of mental disorders are higher within prison populations than in the general
population, and female offenders are more likely than male offenders to be diagnosed
with a mental disorder (Ditton, 1999; Peters, Strozier, Murrin, & Kearns, 1997).
Bloom and Covington (2000) reported that female offenders were more likely to use
serious drugs, to use them more frequently, to inject drugs, and to have a co-existing
Copyright # 2008 John Wiley & Sons, Ltd.
Behav. Sci. Law 26: 413–434 (2008)
DOI: 10.1002/bsl
Treatment outcomes for female offenders: relationship to number of Axis I diagnoses
415
psychiatric disorder compared with male offenders. An assessment of co-occurring
disorders for inmates needing or receiving mental health treatment while in prison
reported 40% of male inmates with at least one Axis I disorder and an active
addiction disorder compared with 57% of female inmates (Blitz, Wolff, Pan, &
Pogorzelski, 2005). In addition, although 59% of women entering prison had at least
one mental disorder (excluding substance abuse/dependence), prison screening
identified only slightly over one-third (Parsons, Walker, & Grubin, 2001), which
indicates that the presence of mental disorder among women in the criminal justice
system may be under-reported. Compared with men, female prisoners were more
likely to report depression, anxiety, low self-esteem, and use of prescribed
medications for psychological problems (Peters et al., 1997). Similarly, Langan
and Pelissier (2001) identified several problem areas that are more prevalent among
incarcerated women as compared with men, including poor physical health, lack of
education, and a troubled childhood/family environment.
Female Offenders with Co-occurring Disorders
The patterns of co-occurring disorders among women in criminal justice systems are
similar to, but more severe than, those found for women in community-based
treatment studies (Sacks, 2004). Female inmates, compared with women in
community epidemiologic studies, have elevated rates of substance use and mental
health disorders, including substance abuse and dependence, mood disorders,
borderline personality, and PTSD (Jordan, Schlenger, Fairbank, & Caddell, 1996;
Maden, Swinton, & Gunn, 1994; Teplin, Abram, & McClelland, 1996). Women in
prison, as well as in community-based substance abuse treatment, report high rates
of exposure to physical and sexual assault, including childhood abuse, and many
exhibit symptoms of posttraumatic stress disorder (PTSD); estimates of the rate of
PTSD among women with substance use disorders range from 30 to 59 percent
(Brown, Recupero, & Stout, 1995). Women with PTSD have poor retention and
outcomes in substance abuse treatment (Hien, Cohen, Miele, Litt, & Capstick,
2004; Hien & Scheier, 1996; Zweben et al., 2004).
A recent study found that many offenders who need or receive mental health
treatment while in prison have multiple Axis I diagnoses, and that the clusters of
diagnoses differ by gender (Blitz et al., 2005). These data have implications for the
gender-specific treatment needs of female offenders. Current correctional substance
abuse treatment programs are often not designed to meet the complex array of
problems typical of offenders with co-occurring disorders (Peters et al., 2004), and
fewer still are designed to meet the specialized treatment needs of female offenders
(Grella, Stein, & Greenwell, 2005; Hills, 2003; Mullings, Marquart, & Hartley,
2003). Some treatment models have been developed for offenders with particular
diagnoses (Najavits, 2003), but none have taken into consideration that the
diagnosed disorder may be part of a complex Axis I mental health diagnostic profile,
creating a need for a different approach to treatment. The degree to which more
sophisticated diagnostic assessment can identify the presence of multiple Axis I
mental health diagnoses for an individual has important implications for the
provision of effective treatment interventions. Comprehensive prison treatment
programs for men, with integrated mental health and substance abuse treatment for
Copyright # 2008 John Wiley & Sons, Ltd.
Behav. Sci. Law 26: 413–434 (2008)
DOI: 10.1002/bsl
416
J. Y. Sacks et al.
co-occurring disorders, can reduce recidivism and improve post-prison substance
use outcomes (Sacks et al., 2004a), but little research has examined the efficacy of
such programs for the female offender with a complex Axis I diagnostic profile.
Effectiveness of Therapeutic Community Treatment for
Substance-Using Offenders
Despite the extensive service and treatment needs of offender populations, effective
programs have been identified. Therapeutic community (TC) treatment has proven to
be effective across a variety of populations and settings, including in the community
(see, e.g., De Leon, 1984; Hubbard, Rachal, Craddock, & Cavanaugh, 1984;
Simpson & Sells, 1982) and in prisons (see, e.g., Hser, Anglin, & Powers, 1993;
Wexler, Falkin, & Lipton, 1990). A modified TC, developed for male offenders with
co-occurring severe mental illness and substance use disorders, demonstrated
significantly greater reductions in reincarceration rates and substance use compared
with a mental health control group (Sacks et al., 2004a; Sullivan, McKendrick,
Sacks, & Banks, 2007).
In the parent study (Sacks et al., 2008) to the research reported here, a modified
TC developed for female offenders with co-occurring severe mental illness and
substance use disorders showed significantly better 6 month post-prison outcomes
for participants randomly assigned to the prison modified TC, compared with those
assigned to a control condition (i.e. cognitive behavioral treatment) on measures of
criminal activity (arrests), HIV sexual-risk behavior, and mental health (depression,
and post-traumatic symptom severity).
To develop the most effective prison treatment options for female offenders with
substance use, more needs to be understood about the clusters of Axis I mental
health disorders that co-occur with their substance use/abuse and the extent to which
the number of co-occurring Axis I mental health diagnoses is related to successful
response to treatment.
The Study
Although recent research has established the importance of prison treatment for cooccurring disorders, and has provided evidence that specific mental health diagnoses
may impede response to substance abuse treatment, studies have not differentiated
treatment outcomes for those offenders with a complexity of multiple Axis I
diagnoses. The study reported in this article examined the functioning of female
offenders with substance use disorders and a range of Axis I diagnoses, and evaluated
offender functioning and treatment response in relation to diagnostic complexity.
Three critical issues have an impact on female criminal etiology and treatment
success: mental health, substance abuse, and trauma. While these issues are linked,
historically, each has been examined separately, and little research has considered
the combined or additive effect (e.g. Blitz et al., 2005). The study reported in this
article uses data from a subset of participants for whom diagnostic information was
available to identify disparities and dysfunction associated with multiple mental
diagnoses at baseline and to explore the extent to which the number of co-occurring
Copyright # 2008 John Wiley & Sons, Ltd.
Behav. Sci. Law 26: 413–434 (2008)
DOI: 10.1002/bsl
Treatment outcomes for female offenders: relationship to number of Axis I diagnoses
417
Axis I mental health diagnoses affected the effectiveness of correctional treatment
delivered to female offenders with substance use problems. This paper uses the term
‘‘diagnostic complexity’’ to denote multiple Axis I mental health diagnoses.
Hypothesis 1 of the study was that the number of Axis I mental diagnoses would be
associated with greater symptomatic and behavioral dysfunction at baseline. The
moderating effects of multiple Axis I psychiatric disorders on the responsiveness of
female offenders to prison TC treatment, compared with a less intense control
condition (cognitive behavioral treatment), was also investigated. The expectation of
this study was that an increase in the number of Axis I psychiatric disorders would
increase the challenges of treating patients. Hypothesis 2 was that, despite significant
treatment effects associated with the TC condition, participants with more Axis I
diagnoses would report comparatively less improvement at 6 months post-prison
release. Hypothesis 3 was that the TC condition, which addresses emotional coping
skills as an integral component of the program (the comparison cognitive behavioral
program did not contain a comparable component), would produce more positive
treatment effects for participants with greater diagnostic complexity.
METHOD
Research Design
The analyses reported in this article included the subset of participants who had been
randomly selected at baseline to complete Modules A, D, E, F, G, L, and P
(demographic information, generalized anxiety disorder, PTSD, depressive
disorder, manic/hypo manic, ADD/ADHD, and ASP-adult) of the Diagnostic
Interview Survey (DIS-IV; Robins, Cottler, Bucholz, & Compton, 1995). Disparities
and dysfunction at baseline were assessed followed by an investigation of 6 month
post-prison outcomes. This paper discusses analyses of the number of Axis I DSMIV mental diagnoses, as a measure of diagnostic complexity, in relation to profiles at
intake and to treatment outcomes at 6 months post-prison release. The number of
Axis I mental diagnoses was expected to be associated with greater symptomatic and
behavioral dysfunction at intake across five domains (i.e. mental health, trauma
exposure, substance use, HIV needle risk behaviors, and HIV sexual risk).
Examination of 6 month post-prison outcomes in relation to the number of Axis I
diagnoses will add to our understanding of the nature of co-occurring disorders and
treatment engagement for this population of incarcerated women. The primary aim
of this research was to test two hypotheses: (1) that, despite significant treatment
effects associated with the TC condition, participants with more diagnoses would
report comparatively less improvement at 6 months post-prison release across the
same five domains; and (2) that the TC condition would produce more positive
treatment effects for participants with greater mental health diagnostic complexity
compared with the control condition.
Research Procedures
The study employed a prospective, longitudinal, repeated measures design to
evaluate participants at five points: baseline (entry into prison treatment); prison
Copyright # 2008 John Wiley & Sons, Ltd.
Behav. Sci. Law 26: 413–434 (2008)
DOI: 10.1002/bsl
418
J. Y. Sacks et al.
discharge; 6 months post-prison release; 12 months post-prison release; and
18 months post-prison release. Eligibility criteria required that study participants
have (1) at least 6 months (and no more than 24 months) remaining until parole
eligibility, (2) a Colorado Department of Corrections (CDOC) Standardized
Offender Assessment (CDOC, 2004) substance abuse score indicative of serious
substance abuse problems requiring substance abuse treatment, and (3) a security
risk level classification of minimum, minimum-restricted, or medium to permit
participation in treatment. Within the first month of admission to the Denver
Women’s Correctional Facility (DWCF), eligible inmates were contacted by a
trained and experienced interviewer, who explained the study and who obtained the
informed consent of the women who volunteered to participate in the research.
Female inmates who consented to participate in the research at prison entry
(baseline) were randomly assigned to one of two treatment conditions, E[xperimental] (an experimental TC) or C[ontrol] (cognitive behavioral treatment).
Sample
Of the 584 female inmates who entered the study, 220 (37.7%) were randomly
selected to complete selected modules of the DSM-IV DIS-IV. A total of 193 who
completed the DIS-IV were eligible for a 6 month post-prison discharge interview.
This study included 147 (147/193 ¼ 76.2%) inmates who were retrieved and who
completed a 6 month post-prison discharge interview.
The reasons that 46 women were not retrieved were that one had deceased,
17 refused, 24 were not located within the acceptable time period, and 4 participants
were scheduled but not yet interviewed. Only three significant profile differences
emerged when comparing participants retrieved at 6 month post-prison release to
those not retrieved. The retrieved sample was more likely to report having sex with an
intravenous drug user in the last 6 months (23.1 versus 7.1%; p < 0.03), was less
likely to have an Attention Deficit/Hyperactivity disorder (ADHD; 10.9 versus
28.6%; p < 0.01), and was less likely to report running away from home
(56.9 versus 76.2%; p < 0.03). Two significant differences emerged for participants
randomly selected to complete the DIS-IV compared with those not selected;
specifically, participants who completed the DIS-IV sections were more likely to
have a high school diploma or GED ( p < 0.03) and reported more symptoms on the
BDI total ( p < 0.04).
Treatment Interventions
Both treatment conditions provided intensive substance abuse and mental health
treatment services within the prison; however, E services were integrated within the
TC treatment program, whereas C services were delivered as separate, discrete
interventions.
The Therapeutic Community (TC)–Experimental (E) Condition
The experimental TC is a 6–9 month program located in a separate 72-bed unit within
the prison. Inmates progressed through four program stages with upper level inmates
Copyright # 2008 John Wiley & Sons, Ltd.
Behav. Sci. Law 26: 413–434 (2008)
DOI: 10.1002/bsl
Treatment outcomes for female offenders: relationship to number of Axis I diagnoses
419
functioning as peer mentors for newer members. The comprehensive TC treatment
program focused on increasing awareness and understanding female roles and
relationships as they relate to addiction and drugs used and abused, and emotional
and behavioral coping skills. Program elements addressed issues of substance abuse,
relapse prevention, mental health, criminal thinking and behavior, coping with
trauma and abuse, and parenting skills. All staff received special training related to
working with women exposed to trauma and abuse, making the program ‘‘trauma
informed’’ and ‘‘trauma sensitive.’’ In addition, the women participated in three
facility-wide services: mental health (psychiatric assessment, medication, individual
counseling), education (GED and Adult Basic Education classes), and health care
(medical and dental treatment).
On average, study participants remained in the program 6.5 months. Formal
program activities (individual and group interventions), took place 5 days each week
for 4 hours each day; women also worked in correctional industries 4 hours/day.
The Intensive Outpatient Program (IOP)–Control (C) Condition
The comparison intervention, called Intensive Outpatient Treatment (IOP) at the
prison, was designed to address substance abuse and criminality, with a focus on
prevention of relapse and recidivism. The IOP substance abuse treatment
curriculum consisted of a 90 hour manualized course (Strategies for Self-Improvement
and Change, Wanburg & Milkman, 1998), utilizing a cognitive behavioral format to
address underlying issues of substance use/abuse and criminal behavior. The course
was completed within 15 weeks. The IOP women also received facility-wide mental
health services (psychiatric assessment, psychotropic medication, and individual
counseling), education (GED and Adult Basic Education classes) and health care
(medical and dental treatment) and had access to parenting and other classes offered
by the prison. Inmates in the IOP attended classroom activities 2 days per week for
2 hours each day, and worked in correctional industries daily, except when attending
classes. Overall, women in the IOP (C group) received their services in
approximately 6–9 months.
Data Collection Measures
Reported data were collected at baseline (prison treatment entry) and at 6 months
post-prison release using standardized self-report instruments, administered by a
research associate to all participants in face-to-face interviews; additional data were
obtained from CDOC computerized information system sources. On average,
baseline interviews took two and a half hours to complete. Participants were given
monetary compensation of $35 for the baseline interview and $25 for the follow-up
interview. The self-report instruments have all proven to be appropriate and effective
in a variety of ethnic, gender, and cultural contexts (see, e.g., Sacks, Banks,
McKendrick, & Sacks, 2008a; Sacks et al., 2008b; Sacks, Sacks, & De Leon, 1999;
Sacks et al., 2004a, 2004b).
The Center for Therapeutic Community Research (CTCR) Baseline Protocol
(CTCR, 1992) was adapted from the TCU Drug Abuse Treatment Assessment
Copyright # 2008 John Wiley & Sons, Ltd.
Behav. Sci. Law 26: 413–434 (2008)
DOI: 10.1002/bsl
420
J. Y. Sacks et al.
Research (DATAR) intake form, the Addiction Severity Index (ASI) (McLellan,
Alterman, Cacciola, Metzger, & O’Brien, 1992), and the TCU AIDS Risk Assessment
(Simpson, 1997). The CTCR protocol assesses socio-demographic/background
variables (age, sex, ethnicity, health, education, employment, parenting, peer and
family support, and housing), self-reported lifetime and current substance use,
criminal behaviors, and HIV-risk behaviors. The CTCR Baseline Protocol also
gathers information regarding perceived psychological symptoms (e.g. prevalence of
suicidal thoughts and actions) and treatment history including inpatient and
outpatient treatment for psychological problems and substance use. Same day,
alternate forms reliability for alcohol and nine drug categories, measured in terms of
percent exact agreement, averaged 94% (range 82–100%) in a similar sample of
women (Sacks et al., 1999). Intake data were collected for lifetime and activity/status
in the 6 months prior to incarceration. Community follow-up interviews reported
activity/status in the 6 months post prison exit.
Substance use and related problems were assessed using self-reported information
about the historic and current frequency of use of alcohol, nine categories of illegal
drugs, and historic and current substance abuse treatment.
HIV/AIDS risk was assessed using self-reported information on needle risk and
sexual risk behaviors. Needle risk included measures of any intravenous drug use.
HIV sexual risk practices included two measures: exchanging sex for money or drugs,
and having unprotected sex with two or more male partners.
Psychiatric Diagnosis
The Diagnostic Interview Schedule (DIS-IV) (Robins et al., 1995) is a structured
clinical interview that generated DSM-IV lifetime and current psychiatric and
substance abuse/dependence diagnoses. Seven diagnostic modules (A, D, E, F, G, L,
P) were administered at baseline to a sub-sample of 220 participants to estimate the
prevalence of co-occurring disorders in the study sample. Modules from the DIS-IV
were administered, rather than the entire interview, to minimize baseline interview
time. The Axis I modules were selected on the basis of reported prevalence in the
system (Stommel, personal communication, September 8, 2001). Diagnoses from
other modules (e.g. schizophrenia, personality disorders) were not assessed, and
inmates with such disorders were expected to be intermixed within both treatment
conditions.
Psychological Symptoms/Functioning and Exposure to Trauma
Information on psychological symptoms and functioning, and exposure to trauma or
abuse, was gathered from four sources, as described below.
The Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) was used
to assess domains of depression consistent with the DSM-IV criteria for depressive
disorders.
The Brief Symptom Inventory (BSI; Derogatis, 1993) is a shortened, revised
version of the Symptom Checklist Revised-90 (Derogatis, 1977), which provides a
measure of nine domains of mental health symptoms and a global index of distress,
the Global Severity Index (GSI).
Copyright # 2008 John Wiley & Sons, Ltd.
Behav. Sci. Law 26: 413–434 (2008)
DOI: 10.1002/bsl
Treatment outcomes for female offenders: relationship to number of Axis I diagnoses
421
The Posttraumatic Symptom Severity Scale (PSS) of the Post-traumatic Stress
Diagnostic Scale (PDS; Foa, Cashman, Jaycox, & Perry, 1997) was used to assess the
severity of post-traumatic stress disorder (PTSD) symptoms in a classification
schema corresponding to DSM-IV PTSD symptoms (‘‘Re-experiencing,’’ ‘‘Avoidance,’’ ‘‘Arousal’’). The PTSD symptom severity score can range from 0 to 51, with
higher scores on the PSS corresponding to greater severity of post-traumatic stress
symptoms.
The Trauma History Questionnaire (THQ; Green, 1996) measured lifetime,
recent, and childhood (under age 14) exposure to community, physical, and sexual
trauma and abuse. Test/retest reliability of the 65 THQ items (over 2–3 months)
ranged from 0.47 to 1.00 (average 0.65) (Green et al., 2000).
Analytic Plan
Descriptive analyses were conducted to investigate baseline differences by diagnostic
complexity as required to test Hypothesis 1. Table 1 shows many variables of
interest, arranged according to the number of diagnoses (dx) collapsed into four
groups: no DSM-IV Axis I diagnosis (0dx), one diagnosis (1dx), two or three
diagnoses (2–3dx), or four or more diagnoses (4þdx). The degree of equivalence
between the four groups at baseline was assessed using chi-square and one-way
ANOVA analyses. An intent-to-treat analysis of change from baseline to 6 months
post-prison release was conducted for five key outcome domains: mental health
(BDI total, GSI total, PSS trauma severity index), trauma exposure (THQ any
physical violence, THQ any sexual violence), substance use (any drug use, severity of
drug use), HIV needle risk (any intravenous drug use), and HIV sexual risk (any
exchange of sex for money/drugs, unprotected sex with more than two male
partners). Z-scores were computed for the ten outcome measures, then averaged
within each domain; for example, Z-scores for the GSI, BDI-II Total, and PSS were
averaged to create a composite outcome score for mental health. To control for
activity/status at intake, baseline data were used to compute Z-scores for the ten
outcomes and composite scores. Z-scores were computed so that a higher score
meant more activity or greater severity reported.
To address Hypothesis 2, the relationship between the number of DSM-IV Axis I
diagnoses and outcomes at the 6 month follow-up assessment was evaluated using
multivariate analysis of covariance (MANCOVA). The main effect for treatment
(independent variable) was assessed for the composites of the five outcome domains
(dependent variables), controlling for the number of diagnoses and the baseline
equivalents of the outcome measures (covariates). In accordance with the findings of
the earlier report (Sacks et al., 2008), a significant treatment effect favoring the TC
condition was expected at the 6 month follow-up; a significant difference was also
expected in the number of DSM-IV Axis I diagnoses, indicative of a negative
relationship between the number of diagnoses and the degree of improvement.
Finally, the interaction between treatment condition and number of diagnoses was
examined to test whether, compared with the control condition, the TC (E)
condition would generate more positive treatment effects for those participants
whose mental health diagnostic status was more complex.
Copyright # 2008 John Wiley & Sons, Ltd.
Behav. Sci. Law 26: 413–434 (2008)
DOI: 10.1002/bsl
422
J. Y. Sacks et al.
Table 1. Comparison of 147 female offenders by number of DIS-IV diagnoses (Hypothesis 1)
DSM-IV diagnosis1
Major depression
PTSD
Generalized anxiety
Manic/hypomanic
Bipolar I/II
ADD/ADHD
Demographics
Age
Race
Caucasian
African American/Black
Hispanic
Other
Marital status—never married
High-school diploma/GED
L6 number of residences
Family history
Parent use/abused substance
Parent had mental health problem
Ran away
Criminality
Age first illegal activity
Age first prison incarceration
LT number of arrests
LT sex offense (prostitution)
Mental health
Beck Depression Total
Brief Symptom Index
Brief Symptom Index 63þ
Post-Traumatic Symptom Severity
Post-Traumatic Symptom 36þ
LT attempted suicide
LT inpatient mental health tx
Current psychiatric medication
Trauma/abuse
LT trauma/abuse exposure
LT sexual violence
L6 trauma/abuse exposure
L6 community violence
L6 physical violence
L6 sexual violence
Trauma/abuse before age 14
Substance use
Age first alcohol use
Age first drug use
LT number types of drug used
LT opiate use
L6 alcohol use
L6 frequency of alcohol use2,3
L6 drug use
L6 sum frequency of drug use4
HIV—needle risk behaviors
LT intravenous drug use
L6 intravenous drug use
0dx
(N ¼ 40)
%/mean
(std)
1dx
(N ¼ 29)
%/mean
(std)
2–3dx
(N ¼ 48)
%/mean
(std)
4þdx
(N ¼ 30)
%/mean
(std)
p
0.0
0.0
0.0
0.0
0.0
0.0
62.1
20.7
10.3
6.9
0.0
0.0
87.5
70.8
31.3
16.7
16.7
14.6
100.0
73.3
66.7
100.0
100.0
30.0
.000***
.000***
.000***
.000***
.000***
.000***
34.7 (8.1)
35.3 (8.8)
36.5 (6.9)
34.4 (8.2)
.645
47.5
15.0
32.5
5.0
35.0
70.0
2.0 (1.7)
37.9
24.1
20.7
17.2
20.7
72.4
1.7 (1.9)
52.1
12.5
20.8
14.6
25.0
68.8
2.0 (1.7)
46.7
26.7
16.7
10.0
30.0
63.3
3.1 (3.0)
.479
.458
.892
.031*
55.0
20.5
43.6
59.3
17.2
55.2
78.7
38.3
58.7
64.3
40.0
73.3
.108
.074
.101
13.7 (5.2) 13.3 (3.7) 12.1 (3.4) 12.4 (4.8)
31.4 (8.1) 30.8 (8.6) 32.1 (7.2) 29.2 (7.8)
10.0 (15.0) 12.0 (12.5) 13.9 (11.2) 12.7 (10.2)
7.5
31.0
33.3
50.0
.305
.449
.453
.001***
12.7 (8.1)
51.6 (9.5)
10.0
8.1 (9.0)
0.0
20.0
12.5
2.5
.000***
.000***
.000***
.000***
.002**
.026*
.000***
.000***
16.9 (10.8) 20.8 (11.3) 23.4 (11.2)
56.1 (11.7) 61.2 (10.2) 63.9 (6.9)
20.7
47.9
66.7
12.5 (9.8) 19.7 (13.2) 22.9 (13.1)
3.4
20.8
24.1
27.6
37.5
53.3
17.2
35.4
66.7
24.1
47.9
43.3
95.0
55.3
57.5
50.0
30.0
7.5
72.5
100.0
62.1
62.1
62.1
37.9
17.2
48.3
97.9
85.4
75.0
64.6
56.3
20.8
64.6
100.0
96.6
83.3
76.7
60.0
43.3
80.0
.394
.000***
.077
.149
.026*
.003**
.057
14.7 (4.3)
17.1 (6.4)
3.1 (1.8)
15.0
42.5
3.1 (2.1)
57.5
6.7 (4.2)
15.3 (4.0)
16.3 (4.4)
3.4 (1.4)
24.1
48.3
4.1 (2.3)
62.1
7.4 (5.0)
13.7 (3.3)
15.0 (4.6)
4.2 (1.9)
43.8
52.1
4.7 (2.6)
68.8
11.5 (5.8)
13.4 (5.8)
15.0 (3.3)
4.0 (1.9)
40.0
73.3
4.7 (2.9)
80.0
10.7 (6.4)
.269
.196
.028*
.020*
.071
.198
.233
.004**
37.5
20.0
34.5
13.8
56.3
29.2
60.0
36.7
.074
.167
(Continues)
Copyright # 2008 John Wiley & Sons, Ltd.
Behav. Sci. Law 26: 413–434 (2008)
DOI: 10.1002/bsl
Treatment outcomes for female offenders: relationship to number of Axis I diagnoses
423
Table 1. (Continued)
1
DSM-IV diagnosis
HIV—sexual risk behaviors
LT sex for money/drugs
L6 sex for money/drugs
L6 unprotected sex with 2þpartners
0dx
(N ¼ 40)
%/mean
(std)
1dx
(N ¼ 29)
%/mean
(std)
2–3dx
(N ¼ 48)
%/mean
(std)
4þdx
(N ¼ 30)
%/mean
(std)
20.0
12.5
12.8
34.5
13.8
10.7
39.6
20.8
22.9
56.7
30.0
30.0
p
.017*
.255
.173
dx ¼ diagnosis; LT ¼ lifetime; L12 ¼ last 12 months; L6 ¼ last 6 months; tx ¼ treatment.
*p < 0.05; **p < 0.01; ***p < 0.001.
1
Table reports DSM-IV diagnoses assessed at baseline.
2,
Based on a reduced sample of participants who used alcohol: 0dx (n ¼ 17), 1dx (n ¼ 14), 2–3dx (n ¼ 25),
4þdx (n ¼ 22).
3
Frequency codes of substance use: 0 ¼ no use, 1 ¼ once, 2 ¼ a few times, 3 ¼ once a month, 4 ¼ once
every two weeks, 5 ¼ once a week, 6 ¼ several times a week, 7 ¼ every day, 8 ¼ more than once a day.
4
Based on a reduced sample of participants who used drugs: 0dx (n ¼ 23), 1dx (n ¼ 18), 2–3dx (n ¼ 33),
4þdx (n ¼ 24).
An exploratory analysis was conducted into the equivalency of treatment effects
by the number of diagnoses (Hypothesis 3). Hedge’s g effect sizes were computed to
assess differential treatment effects for clients with zero, one, two or three, and four
or more Axis I diagnoses. The E group was expected to report greater improvement
compared with C for each level of Axis I diagnosis. Effect sizes were scaled so that
positive effects indicated greater improvement for the E group, compared with the C
group, from baseline to the 6 month follow-up assessment. A one-sample t-test was
used to determine whether the average effect was significantly greater than zero.
RESULTS
Profiles
Table 1 addresses Hypothesis 1 by presenting demographic and background data for
inmates in the four diagnostic groups. The majority (72.8%) of female offenders, all
of whom had been designated to receive substance abuse treatment, had at least one
Axis I mental health diagnosis. Participants were organized into four diagnostic
categories, according to their DSM-IV Axis I diagnoses: (1) no diagnosis (0dx;
27.2%); (2) one diagnosis (1dx; 19.7%); (3) two or three diagnoses (2–3dx; 32.7%);
and (4) four or more diagnoses (4þdx; 20.4%). The diagnostic profiles of the study
participants, shown in Table 1, revealed that major depression was the most
prevalent disorder overall (62.1, 87.5, and 100.0% for groups with ‘‘1,’’ ‘‘2 or 3,’’
and ‘‘4 or more’’ diagnoses, respectively), followed by PTSD (20.7, 70.8, and 73.3%
for groups with ‘‘1,’’ ‘‘2 or 3,’’ and ‘‘4 or more’’ diagnoses, respectively).
Demographic and Background Characteristics
Significant differences by number of diagnoses were not detected for age, race/
ethnicity, marital status, education, or measures of family history. Participants in the
Copyright # 2008 John Wiley & Sons, Ltd.
Behav. Sci. Law 26: 413–434 (2008)
DOI: 10.1002/bsl
424
J. Y. Sacks et al.
‘‘4 or more’’ diagnoses group had lived in more residences immediately prior to
incarceration ( p < 0.04), and had more lifetime sexual offenses ( p < 0.001) than
participants with fewer diagnoses. The vast majority of measures for criminality,
including measures of onset, incarceration, arrest, and criminal activity, revealed no
differences among the groups.
Mental Health
The three standardized measures of psychological symptoms (BDI-II Total, BSI,
and the PSS Scale) all showed that an increase in the number of Axis I diagnoses had
a significant linear relationship with symptom severity (Table 1). Comparing the
group with no (‘‘0’’) diagnosis and the group with ‘‘4 or more’’ diagnoses revealed
consistently higher values for the latter group; specifically, the average BDI score of
12.7 (sd ¼ 8.1) for the ‘‘0’’ diagnosis group increased to 23.4 (sd ¼ 11.2) for the ‘‘4
or more’’ diagnoses group, the BSI of 51.6 (sd ¼ 9.5) increased to 63.9 (sd ¼ 6.9),
and the PSS of 8.1 (sd ¼ 9.0) increased to 22.9 (sd ¼ 13.1). This pattern was
repeated in the proportion of participants who scored in the clinical range on the BSI
(63 or higher), which increased from 10.0 to 20.7 to 47.9 to 66.7% for the four
groups (‘‘0,’’ ‘‘1,’’ ‘‘2 or 3,’’ and ‘‘4 or more’’ diagnoses, respectively; p < 0.001), as
well as in the percent of participants with a ‘‘severe’’ PSS score (36 or greater), which
was 0.0% in the ‘‘0’’ diagnosis group, increasing to 24.1% in the ‘‘4 or more’’
diagnoses group ( p < 0.002). The symptom profiles mirrored the increasing
diagnostic prevalence of depression and PTSD that occurred as the number of Axis
I diagnoses increased; the prevalence of attempted suicide (lifetime) ranged from
20.0% for the ‘‘0’’ diagnosis group to 53.3% for the ‘‘4 or more’’ diagnoses group
( p < 0.03).
Trauma Exposure
Virtually all (98.0%) participants reported exposure to some form of trauma during
their lifetime, especially community violence (95.9%) and physical violence
(95.9%); 66.7% of the women indicated exposure to trauma prior to age fourteen.
These measures showed no statistical differences by number of Axis I diagnoses. The
statistical differences that were detected indicated greater exposure to lifetime and
recent interpersonal violence (physical and sexual violence) for participants with
more Axis I diagnoses. Exposure to sexual violence, which was 55.3% for those with
no Axis I diagnosis, increased to 96.6% for those with four or more diagnoses
( p < 0.001). Thirty percent of inmates with no Axis I diagnosis reported physical
violence in the 6 months prior to incarceration; this proportion doubled to 60.0% for
inmates with four or more diagnoses ( p < 0.03).
Substance use
All offenders who participated in the study were substance users as designated by
the CDOC assessment, which evaluates the severity of historic and current drug use
behavior and drug-related crime. A linear relationship was observed between the
Copyright # 2008 John Wiley & Sons, Ltd.
Behav. Sci. Law 26: 413–434 (2008)
DOI: 10.1002/bsl
Treatment outcomes for female offenders: relationship to number of Axis I diagnoses
425
number of Axis I mental health diagnoses and use of more types of illegal drug
(lifetime), use of opiates (lifetime), and frequency of drug use prior to prison
admission.
HIV Risk Behaviors
A linear pattern was again detected for lifetime HIV sexual-risk behavior.
Participants with more psychiatric diagnoses were more likely to report having
sex for money or drugs (lifetime). Differences were not detected among the groups
on measures of needle use or sexual activity in the 6 months prior to incarceration.
Outcomes at 6 Months Post-prison Release
Results for the MANCOVA analysis to address Hypothesis 2 are presented in
Table 2. Contrary to the hypothesis, the number of DSM-IV Axis I diagnoses was
not related to improvement at follow-up. With respect to Hypothesis 3, testing of the
interaction between treatment condition and the number of diagnoses also showed
divergent results. A significant treatment main effect did emerge, favoring the E
condition ( p < 0.02), overall and specifically for the domains of mental health
( p < 0.01) and HIV sexual risk behavior ( p < 0.03).
Although the interaction term between treatment group and number of mental
diagnoses was not significant, Table 3 presents results of follow-up, exploratory
analyses using Hedge’s g effect sizes to assess differential treatment effects for clients
with ‘‘0,’’ ‘‘1,’’ ‘‘2 or 3,’’ and ‘‘4 or more’’ Axis I diagnoses. Hedge’s g effects were
scaled so that a positive effect would indicate greater improvement for the E group,
compared with the C group, from baseline to 6 months post-prison release. As
shown in Table 3, all but one of the domain level effects was positive, indicating
greater improvement for the E condition, compared with the C group, from baseline
to 6 months post-prison release. These findings support those found in an earlier
report of preliminary analyses (Sacks et al., 2008). The differences in the Hedge’s g
effects for the ‘‘4 or more’’ diagnoses group, although sizable, did not produce a
significant interaction effect; therefore, the difference could be the result of simple
random variation.
Table 2. MANCOVA results (Hypothesis 2)
Main effects
Domain-level effects
Mental health
Interpersonal violence
Drug use
HIV needle risk
HIV sexual risk
E (n ¼ 90)
Z-score
mean (std)
C (n ¼ 57)
Z-score
mean (std)
—
—
0.252 (0.750)
0.193 (0.583)
0.156 (0.653)
0.059 (0.863)
0.183 (0.374)
—
—
0.023 (0.845)
0.033 (0.866)
0.046 (0.807)
0.051 (0.704)
0.018 (0.807)
E vs. C
Partial
eta sq. ( p)
0.097 (.016*)
0.063
0.024
0.008
0.000
0.037
(0.003**)
(0.068)
(0.286)
(0.873)
(0.023*)
No. of diagnoses
Partial
eta sq. ( p)
0.008 (.958)
0.000
0.002
0.000
0.002
0.001
(0.864)
(0.612)
(0.809)
(0.629)
(0.750)
*p < 0.05; **p < 0.01.
Copyright # 2008 John Wiley & Sons, Ltd.
Behav. Sci. Law 26: 413–434 (2008)
DOI: 10.1002/bsl
426
J. Y. Sacks et al.
Table 3. Hedge’s g effect sizesy —E versus C treatment effects by number of Axis I mental disorders
(Hypothesis 3)
Mental health composite
BDI total score
BSI global severity
PSS trauma severity index
Trauma exposure composite
Physical violence
Sexual violence
Substance use composite
Any drug use
Sum freq. drug use
HIV needle risk composite
HIV sexual risk composite
Sex for money/drugs
Unprotected sex w/2þ
0dx
(24 E & 16 C)
Hedge’s g
1dx
(20 E & 9 C)
Hedge’s g
2–3dx
(28 E & 20 C)
Hedge’s g
4þdx
(18 E & 12 C)
Hedge’s g
0.295
0.341
0.397
0.147
0.026
0.146
0.198
0.049
0.086
0.012
0.156
0.181
0.328
0.033
0.249
0.272
0.309
0.167
0.009
0.085
0.103
0.045
0.048
0.041
0.016
0.285
0.262
0.308
0.021
0.189
0.093
0.033
0.071
0.000
0.141
0.013
0.031
0.057
0.000
0.040
0.017
0.063
0.384
0.473
0.296
0.384
0.321
0.398
0.243
0.172
0.129
0.214
0.137
0.112
0.177
0.047
y
Positive Hedge’s g effects indicate greater improvement for the E group compared with C from baseline to
6 month post-prison release.
dx ¼ diagnosis.
DISCUSSION
Summary of Findings
Over three-quarters of the female, substance-abusing offenders in this study had at
least one Axis I mental health diagnosis; since the study population consisted only of
those women identified as needing substance abuse treatment, it provides important
confirmation that women in prison with substance abuse problems are highly likely
to have a co-occurring serious mental disorder. Over half of the participants had two
or more Axis I serious mental health diagnoses and, within this group, over 70% had
a diagnosis of major depression combined with PTSD. In particular, PTSD affects
interpersonal interactive styles, which may have a negative impact on the offender’s
ability to respond to the interpersonal therapeutic modalities; indeed, in communitybased studies, women with PTSD were more likely to have poor post-treatment
outcomes. As hypothesized, an increase in the number of Axis I mental health
diagnoses was characterized by a symptom and behavioral profile of increasing
severity.
It was anticipated that Axis I mental health diagnostic complexity, and the
associated symptom severity, would result in poorer post-treatment outcomes;
however, this was not confirmed. It was further hypothesized that TC treatment
would prove to be a more effective treatment approach than the comparison
cognitive behavioral program for women with more complex diagnoses; in the
current study, the prison TC treatment, as modified for female offenders, was more
effective than the comparison treatment across all diagnostic groups.
Copyright # 2008 John Wiley & Sons, Ltd.
Behav. Sci. Law 26: 413–434 (2008)
DOI: 10.1002/bsl
Treatment outcomes for female offenders: relationship to number of Axis I diagnoses
427
Multiple Diagnoses
Few studies have explored the complexity of diagnostic profiles of women in prison
and related these to prison treatment outcomes. In this age of diminishing resources
for all treatment, including offender services, understanding the risk factors for
relapse and recidivism among substance abusers in prison and the effectiveness of
treatments for specialized offender sub-populations can guide the efficient use of
treatment resources. This study demonstrates that female inmates who enter prison
with a history of chronic and severe substance use and substance-related crimes are
highly likely to have a co-occurring mental disorder, and that a significant percentage
of these will be Axis I severe mental health disorders; indeed, the study revealed that
such women are likely to have multiple Axis I psychiatric disorders. Furthermore, an
increase in the number of diagnoses elevated the probability that PTSD would be
present. In particular, PTSD affects interpersonal interactive styles, which could have
a negative impact on the offender’s ability to respond to the interpersonal therapeutic
modalities; indeed, in community-based studies, women with PTSD were more likely
to have poor post-treatment outcomes. An earlier study (Blitz et al., 2005)
demonstrated that, among women who the correction system identified as needing or
receiving prison mental health services, 23% had additional co-occurring Axis I
mental health diagnoses, according to prison-system assessments and diagnoses. The
present study expands our understanding of the prevalence and nature of cooccurring multiple Axis I mental health disorders for female offenders by extending
the population under study to female offenders identified as needing substance abuse
treatment, and by determining diagnoses using an independent research instrument
(DIS-IV), rather than relying on diagnoses that may have been more subjectively
determined by multiple diagnosticians within the correctional setting. In this report,
73% of the female offenders with substance use/abuse also had an Axis I diagnosis,
and over half (53%) had multiple Axis I diagnoses. The current findings are
consistent with the literature for prevalence of any mental disorder among
participants in community-based substance abuse treatment programs and suggest
greater prevalence of severe mental disorders among female offenders in prison
substance abuse treatment programs, as compared with mixed gender samples from
community-based treatment programs (Compton et al., 2000; Sacks et al., 1997).
The cumulative profile for this sample of female offenders supports using the
number of Axis I diagnoses as a proxy for diagnostic severity. Of the women with two
or three Axis I mental health diagnoses, almost all (88%) had a diagnosis of major
depression, and over 70% had PTSD. Of the women with four or more diagnoses, all
had diagnoses of major depression, manic/hypomanic, and bi-polar disorder; nearly
three-quarters had a concurrent diagnosis of PTSD. Multiple psychiatric diagnoses
were associated with increased severity and complexity of several mental health
symptoms.
These findings have important implications for treatment planning and for
delivery of treatment services to female offenders with substance use problems. The
complex needs of female offenders have been widely documented in the literature.
Treatment models that focus on only one diagnosis may not sufficiently address
the needs of women with two or three different psychiatric diagnoses; more
comprehensive prison treatment programming for female offenders may be the
Copyright # 2008 John Wiley & Sons, Ltd.
Behav. Sci. Law 26: 413–434 (2008)
DOI: 10.1002/bsl
428
J. Y. Sacks et al.
intervention of choice for meeting the interrelated needs of women in the criminal
justice system who have multiple psychiatric diagnoses, accompanied by severe
emotional, behavioral and lifestyle disabilities and dysfunction.
The prevalence data also point to the need for better mental health screening,
assessment, diagnostic and treatment procedures for female offenders, including
rapid determination of a need for psychopharmacological and other mental health
interventions. Effective treatment cannot be offered if individual needs are not
assessed thoroughly. Recent studies and reviews have identified appropriate
instruments for screening (Sacks, 2008; Sacks et al., 2007a, 2007b) and assessment
(Peters, Bartoi, & Sherman, unpublished document) and have determined those
psychopharmacological interventions that are most effective in treating individuals
with severe mental disorders (Green, Drake, Brunette, & Noordsy, 2007; Lieberman
et al., 2005).
Six-month Post-prison Outcomes: Number of Diagnoses
Contrary to the hypothesis, the primary analysis (using MANCOVA) did not find a
significant relationship between number of DSM-IV Axis I diagnoses and
improvement at follow-up; women in all diagnostic groups improved. That is,
there was no evidence that female offenders with more diagnoses were less able to
benefit from prison substance abuse treatment. A potential factor influencing this
outcome is that all women at Denver Women’s Correctional Facility (DWCF)
receive, upon admission, a comprehensive standardized assessment for mental
health and substance abuse treatment needs, which identifies those women who are
to receive follow-up psychiatric assessment, psychopharmacology, and mental
health counseling, as well as substance abuse treatment, as indicated. Prison
resources are allocated so that all women who are assessed as needing psychiatric
assessment and psycho-pharmacological treatment receive such services without
delay. In this study, for those offenders with more severe diagnostic profiles, the
rapid provision of psychotropic medication to stabilize symptoms may have
facilitated responsiveness to the substance abuse treatment programs.
Six-month Post-prison Outcomes: E Versus C
The study did not find a significant interaction between the number of diagnoses and
treatment condition at follow-up, which is reflected in the primary analysis and in the
pattern of effect sizes. For all diagnostic groups, the TC, as modified for female
offenders, was significantly more effective than the control cognitive behavioral
program overall, and on measures of mental health symptoms and HIV sexual risk.
Recent studies of women receiving community-based programming found that
counseling with an integrated focus on substance abuse, trauma, and mental health
issues had promising substance abuse and mental health outcomes (Cocozza et al.,
2005; Morrissey et al., 2005). The TC prison treatment that proved effective for the
participants in this study was adapted to suit female offenders in several ways;
programming was trauma informed and trauma sensitive by virtue of ensuring staff
training regarding the functional impacts of historic exposure to trauma/abuse;
Copyright # 2008 John Wiley & Sons, Ltd.
Behav. Sci. Law 26: 413–434 (2008)
DOI: 10.1002/bsl
Treatment outcomes for female offenders: relationship to number of Axis I diagnoses
429
screening/assessment and treatment planning for co-occurring serious mental illness
and substance use disorders for all entering inmates was assured; timely access to
psychopharmacology and mental health counseling was integrated within the
program; and the program incorporated components for dual recovery and to impart
the emotional and behavioral coping skills needed to prevent relapse and recidivism.
The findings reported here suggest that this TC treatment program, as modified,
represents an effective model of treatment for female offenders with co-occurring
disorders whose diagnoses and symptom severities vary in complexity.
Sensitivity Analysis
As an alternative to the number of diagnoses, sensitivity tests were conducted to
explore the relationship between individual diagnoses and outcomes at the 6 month
follow-up using MANCOVA. The main effects (as well as domain-level effects) for
three lifetime diagnoses (major depression, bipolar I/II, and PTSD) were not
significant in predicting change from baseline to 6 months post-prison release. A
second sensitivity analysis was conducted for current (in the past year) number of
diagnoses. Again, the main effect resulting for the number of diagnoses was not
significant. A third test of current psychological symptomatology also found no
significant relationship between the symptoms reported at intake and those cited at
outcome, 6 months after prison release, even when the subject pool included only
those with clinically severe symptom levels (GSI > 63). The TC was significantly
more effective than the control treatment for all of these models, supporting the
evidence of effectiveness of the TC, as modified, for female offenders with multiple
diagnoses and diagnostic severity.
Limitations
This report was structured to investigate profile and outcome differences for female
offenders with substance use disorders who had been grouped according to the
complexity of their co-occurring Axis I psychiatric disorders, which was defined as
multiplicity of Axis I mental diagnoses (lifetime). Data were limited to Axis I mental
disorders, and to six modules of the DIS-IV that reflect those diagnoses with greatest
prevalence in the system, and did not include either Axis I substance abuse/
dependence (CDOC assessments had identified all participants as having severe
substance abuse problems that required treatment), Axis II diagnoses, or Axis I
diagnoses of lower prevalence (e.g. psychotic disorders). While acknowledging that
severity is more complicated than can be described by classification according to the
number of positive diagnoses, the findings do show a consistent and linear pattern of
dysfunction associated with the number of Axis I mental disorders. Future research
that focuses on the full array of Axis I and Axis II diagnoses could add greatly to our
understanding of the multiple patterns of diagnostic complexity in the population of
female offenders. Research that is inclusive of the full array of Axis I and Axis II
mental disorders is needed to explore and clarify the needs of offenders with multiple
patterns of diagnostic complexity, and the impact of particular clusters of diagnoses
on treatment outcomes.
Copyright # 2008 John Wiley & Sons, Ltd.
Behav. Sci. Law 26: 413–434 (2008)
DOI: 10.1002/bsl
430
J. Y. Sacks et al.
Although adequate for a preliminary analysis, the sample size was limited to a
subgroup of participants randomly selected to receive the DIS-IV interview.
Analyses investigating selection bias revealed few significant differences between
participants who completed the DIS-IV and those who did not, indicating that
selection bias was minimal.
The analyses presented here did not evaluate other threats to validity, including
treatment dose, time at risk, reincarceration outcomes, or the effects of possible
moderators (e.g. homelessness and recent trauma exposure). Whenever possible,
future research should include tests of moderators, sensitivity, and validity to extend
the main findings. This is particularly relevant in criminal justice settings, where
stakeholders often raise criticisms of findings from offender treatment research (see,
e.g., Farabee, 2005).
Summary and Conclusions
Other studies of the investigative team have demonstrated the effectiveness of a
modified TC program for male offenders with co-occurring disorders in terms of
crime (Sacks et al., 2004a) and substance use outcomes (Sullivan et al., 2007). The
study reported here extends the utility of the modified TC model to include female
offenders across a range of Axis I diagnostic complexity.
The outcomes currently reported are also consistent with the findings from a
recent literature review by Drake, O’Neal, and Wallach (2008), which concluded
that residential programming (including TC treatment) was one of only three
approaches (in addition to group counseling and contingency management) that
were effective in improving substance use outcomes for severely mentally ill clients
with co-occurring substance use disorders. Given today’s cost-consciousness and
limited resources, it is imperative to continue to identify those clients with the
greatest needs who are most likely to benefit from comprehensive treatment
approaches of longer duration. The prison is one setting in which these approaches
might be particularly viable because the incremental cost of such treatments is
relatively modest (French, McCollister, Sacks, McKendrick, & De Leon, 2002;
French, Sacks, De Leon, Staines, & McKendrick, 1999; McCollister et al., 2003).
Correctional systems need to be cognizant of the fact that female offenders with
severe and chronic substance use problems are highly likely to have a co-occurring
mental disorder, and a significant percentage of the women are likely to have multiple
Axis I serious psychiatric disorders. Preliminary data found no relationship between
diagnostic complexity (i.e. the number of Axis I diagnoses) and 6 month post-prison
treatment outcomes across five domains (i.e. mental health, trauma exposure,
substance use, HIV needle risk behaviors, and HIV sexual risk); however, further
research is needed to examine the full array of Axis I and Axis II disorders in relation
to treatment outcome for female offenders. The experimental TC (as modified),
which provides comprehensive, integrated services for female offenders with cooccurring disorders, was significantly more effective than the control cognitive
behavioral program across all mental disorder severity groups overall, and on
measures of mental health symptoms and HIV sexual risk. These preliminary
findings suggest that this TC program, as modified, is an effective model for women
in the correctional system with complex diagnoses and symptom severities.
Copyright # 2008 John Wiley & Sons, Ltd.
Behav. Sci. Law 26: 413–434 (2008)
DOI: 10.1002/bsl
Treatment outcomes for female offenders: relationship to number of Axis I diagnoses
431
ACKNOWLEDGEMENTS
The study was funded under a grant, #5DA014370-[01-05], from the U.S.
Department of Health and Human Services (DHHS), National Institutes of Health
(NIH) and the National Institute on Drug Abuse (NIDA). The contents are solely
the responsibility of the authors and do not necessarily represent the views of the
DHHS, NIH or NIDA.
REFERENCES
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory—Second edition (BDI-II)
manual. San Antonio, TX: Psychological Corporation.
Blitz, C. L., Wolff, N., Pan, K. Y., & Pogorzelski, W. (2005). Gender-specific behavioral health and
community release patterns among New Jersey prison inmates: Implications for treatment and
community reentry. American Journal of Public Health, 95(10), 1741–1746.
Bloom, B., & Covington, S. (2000). Gendered justice: Programming for women in correctional settings. Paper
presented at the 52nd Annual Meeting of the American Society of Criminology, San Francisco,
November 2000.
Blume, S. B. (1990). Alcohol and drug problems in women: Old attitudes, new knowledge. In Milkman,
H. & Sederer L. (Eds.), Treatment choices for alcoholism and substance abuse (pp. 183–198). New York:
Lexington.
Brown, P. J., Recupero, P. R., & Stout, R. L. (1995). PTSD substance abuse comorbidity and treatment
utilization. Addictive Behaviors, 20, 251–254.
Center for Therapeutic Community Research (CTCR). (1992). CTCR Baseline Interview Protocol#.
National Development and Research Institutes: New York.
Cocozza, J. J., Jackson, E. W., Hennigan, K., Morrisey, J. P., Reed, B. G., Fallot, R., & Banks, S. (2005).
Outcomes for women with co-occurring disorders and trauma: Program-level effects. Journal of
Substance Abuse, 28(2), 109–119.
Colorado Department of Corrections (CDOC). (2004). Colorado Standardized Offender Assessment (SOA).
Denver, CO: Author.
Compton, W. M., Cottler, L. B., Abdallah, A. B., Phelps, D. L., Spitznagel, E. L., & Horton, J. C. (2000).
Substance dependence and other psychiatric disorders among drug dependent subjects: Race and
gender correlates. American Journal on Addictions, 9, 113–125.
De Leon, G. (1984). The therapeutic community: Study of effectiveness. National Institute on Drug Abuse
(NIDA) Research Monograph, DHHS Pub No ADM 84-1286. U. S. Government Printing Office:
Washington, DC.
Derogatis, L. R. (1977). SCL-90-R, administration, scoring, and procedures manual 1. Baltimore, MD:
Clinical Psychometric Research.
Derogatis, L. R. (1993). Brief Symptom Inventory administration, scoring, and procedures manual (3rd ed.)
National Computer Systems. Minneapolis, MN.
Ditton, P. M. (1999). Mental health and treatment of inmates and probationers. US Department of Justice
Special Report NCJ-174463. Washington DC: US Department of Justice, Bureau of Justice Statistics.
Drake, R. E., O’Neal, E. L., & Wallach, M. A. (2008). A. systematic review of psychosocial research on
psychosocial interventions for people with co-occurring severe mental and substance use disorders.
Journal of Substance Abuse Treatment, Special Issue: Recent Advances in Research on the Treatment of CoOccurring Disorders, S. Sacks, R. Chandler, & J. Gonzales (Eds.), 34(1), 123–128. DOI: 10.1016/
j.jsat.2007.01.011
Drake, R., Xie, H., McHugo, G., & Shumway, M. (2001). Three-year outcomes of long-term patients
with co-occurring bipolar and substance use disorders. Biological Psychiatry, 56(10), 749–756.
Farabee, D. (2005). Rethinking rehabilitation: Why can’t we reform our criminals?. Washington, DC:
American Enterprise Institute Press.
Foa, E. B., Cashman, L., Jaycox, L., & Perry, K. (1997). The validation of a self-report measure of
posttraumatic stress disorder: The Posttraumatic Diagnostic Scale. Psychological Assessment, 9(4), 445–
451.
French, M. T., McCollister, K. E., Sacks, S., McKendrick, K., & De Leon, G. (2002). Benefit–cost
analysis of a modified TC for mentally ill chemical abusers. Evaluation and Program Planning, 25(2),
137–148.
Copyright # 2008 John Wiley & Sons, Ltd.
Behav. Sci. Law 26: 413–434 (2008)
DOI: 10.1002/bsl
432
J. Y. Sacks et al.
French, M. T., Sacks, S., De Leon, G., Staines, G., & McKendrick, K. (1999). Modified therapeutic
community for mentally ill chemical abusers: outcomes and costs. Evaluation and the Health Professions,
22(1), 60–85.
Green, A. I., Drake, R. E., Brunette, M. D., & Noordsy, D. L. (2007). Schizophrenia and co-occurring
substance use disorder. American Journal of Psychiatry, 164(3), 402–408.
Green, B. L. (1996). Psychometric review of the Trauma History Questionnaire—self report. In B. H.
Stamm (Ed.), Measurement of stress, trauma & adaptation (pp. 366–369). Towson, MD: Sidran.
Green, B. L., Goodman, L. A., Krupnick, J. L., Corcoran, C. B., Petty, R. M., Stockton, P., & Stern,
N. M. (2000). Outcomes of single versus multiple trauma exposure in a screening sample. Journal of
Traumatic Stress, 13(2), 271–286.
Grella, C. E., Stein, J. A., & Greenwell, L. (2005). Associations among childhood trauma, adolescent
problem behaviors, and adverse adult outcomes in substance-abusing women offenders. Psychology of
Addictive Behaviors, 19(1), 43–53.
Hien, D. A., Cohen, L. R., Miele, G. M., Litt, L. C., & Capstick, C. (2004). Promising treatments for
women with comorbid PTSD and substance use disorders. American Journal of Psychiatry, 161, 1426–
1432.
Hien, D., & Scheier, J. (1996). Trauma and short-term outcome for women in detoxification. Journal of
Substance Abuse Treatment, 13, 227–231.
Hills, H. (2003). The special needs of women involved with family drug court. Delmar, NY: GAINS Center.
Hser, Y. I., Anglin, M. D., & Powers, K. (1993). A 24 year follow-up of California narcotics addicts.
Archives of General Psychiatry, 50(1), 477–584.
Hubbard, R. L., Rachal, J. V., Craddock, S. G., & Cavanaugh, E. R. (1984). Treatment outcome
prospective study (TOPS): Client characteristics and behaviors before, during and after treatment. In
F.M. Tims & J.P. Ludford (Eds.), Drug abuse treatment evaluation: Strategies, progress and prospects.
National Institute on Drug Abuse (NIDA) Research Monograph 51, DHHS Pub. No. ADM 84-1329.
U. S. Government Printing Office: Washington, DC.
James, D. J., & Glaze, L. E. (2006). Bureau of Justice Statistics, Special Report: Mental health problems of
prison and jail inmates. U.S. Department of Justice, Office of Justice Programs. Bureau of Justice
Statistics, NCJ213600 (pp. 1-11), September 2006 (revised 12/14/06). Retrieved January 10, 2008,
from http://www.ojp.usdoj.gov/bjs/pub/pdf/mhppji.pdf
Jordan, B. K., Schlenger, W. E., Fairbank, J. A., & Caddell, J. M. (1996). Prevalence of psychiatric
disorders among incarcerated women. II. Convicted felons entering prison. Archives of General
Psychiatry, 53(6), 513–519.
Kubiak, S. (2004). The effects of PTSD on treatment adherence, drug relapse, and criminal recidivism in
a sample of incarcerated women. Research on Social Work Practice, 14, 424–433.
Langan, N. P., & Pelissier, B. M. (2001). Gender differences among prisoners in drug treatment. Journal of
Substance Abuse Treatment, 13(3), 291–301.
Lieberman, J. A., Stroup, T. S., McEvoy, J. P., Swartz, M. S., Rosenheck, R. A., Perkins, D. O., Keefe,
R. S. E., Davis, S. M., Davis, C. E., Lebowitz, B. D., Severe, J., & Hsiao, J. K. (2005). Effectiveness of
antipsychotic drugs in patients with chronic schizophrenia. New England Journal of Medicine, 353, 1209–
1222.
Maden, T., Swinton, M., & Gunn, J. (1994). Psychiatric disorder in women serving a prison sentence.
British Journal of Psychiatry, 164(1), 44–54.
McCollister, K. E., French, M. T., Prendergast, M., Wexler, H., Sacks, S., & Hall, E. (2003). Is in-prison
treatment enough? A cost-effectiveness analysis of prison-based treatment and aftercare services for
substance-abusing offenders. Law and Policy, 25(1), 63–82.
McLellan, A. T., Alterman, A. I., Cacciola, J., Metzger, D., & O’Brien, C. P. (1992). A new measure of
substance abuse treatment: Initial studies of the treatment services review. Journal of Nervous and Mental
Disease, 180(2), 101–110.
McNeil, D., Binder, R., & Robinson, J. (2005). Incarceration associated with homelessness, mental
disorder and co-occurring substance abuse. Psychiatric Services, 56(7), 840–846.
Messina, N., Burdon, W., Hagopian, G., & Prendergast, M. (2004). One year return to custody rates
among co-disordered offenders. Behavioral Science and the Law, 22(4), 503–518.
Monahan, J., Bonnie, R. J., Applebaum, P., Hyde, P. S., Steadman, H., & Swartz, M. (2001). Mandated
Community Treatment: Beyond outpatient commitment. Psychiatric Services, 52, 1198–2005.
Monahan, J., Steadman, H. J., Robbins, P. C., Appelbaum, P., Banks, S., Grisso, T., Heilbrun, K.,
Mulvey, E. P., Roth, L., & Silver, E. (2005). An actuarial model of violence risk assessment for persons
with mental disorders. Psychiatric Services, 56(7), 810–815.
Morrissey, J. P., Ellis, A. R., Gatz, M., Amaro, H., Reed, B. G., Savage, A., Finkelstein, N., Mazelis, R.,
Brown, V., Jackson, E. W., & Banks, S. (2005). Outcomes for women with co-occurring disorders and
trauma: Program and person-level effects. Journal of Substance Abuse Treatment, 28(2), 121–133.
Copyright # 2008 John Wiley & Sons, Ltd.
Behav. Sci. Law 26: 413–434 (2008)
DOI: 10.1002/bsl
Treatment outcomes for female offenders: relationship to number of Axis I diagnoses
433
Mullings, J. L., Marquart, J. W., & Hartley, D. J. (2003). Exploring the effects of childhood sexual abuse
and its impact on HIV/AIDS risk-taking behavior among women prisoners. Prison Journal, 83(4), 442–
463.
Najavits, L. M. (2003). Seeking Safety: A new psychotherapy for posttraumatic stress disorder and
substance use disorder. In P. Ouimette, & P. Brown (Eds.), Trauma and substance abuse: Causes,
consequences, and treatment of comorbid disorders pp 147–170. Washington, DC: American Psychological
Association Press.
Parsons, S., Walker, L., & Grubin, D. (2001). Prevalence of mental disorder in female remand prisons.
Journal of Forensic Psychiatry, 12(1), 194–202 (9).
Peters, R. H., LeVasseur, M. E., & Chandler, R. (2004). Correctional treatment for co-occurring
disorders: Results of a national survey. Behavioral Sciences and the Law (special edition), 22(4),
563–584.
Peters, R. H., Strozier, A. L., Murrin, M. R., & Kearns, W. D. (1997). Treatment of substance-abusing
jail inmates. Examination of gender differences. Journal of Substance Abuse Treatment, 14(4), 339–349.
Regier, D. A., Farmer, M. E., Rae, D. S., Locke, B. Z., Keith, S. J., Judd, L. L., & Goodwin, F. K. (1990).
Comorbidity of mental disorders with alcohol and other drug abuse: Results from the Epidemiologic
Catchment Area (ECA) study. Journal of the American Medical Association, 264(19), 2511–2518.
Robins, L., Cottler, L., Bucholz, K., & Compton, W. (1995). Diagnostic Interview Schedule for DSM-IV
(DIS-IV). Bethesda, MD: National Institute on Mental Health (NIMH).
Robins, L. N., & Reiger, D. A. (1991). Psychiatric disorders in America: The epidemiologic catchment area
study. New York: Free Press.
Sacks, J. Y. (2004). Women with co-occurring substance use and mental disorders (COD) in the criminal
justice system: A research review. Behavioral Sciences and the Law, 22, 477–501.
Sacks, J. Y., Sacks, S., McKendrick, K., Banks, S., Schoeneberger, M., Hamilton, Z., Stommel, J., &
Shoemaker, J. (2008). Prison therapeutic community treatment for female offenders: Profiles and
preliminary findings for mental health and other variables (crime, substance use and HIV risk). Journal
of Offender Rehabilitation (special edition-Current Trends in Probation & Parole, D. W. Phillips, guest ed.),
46(3/4), 233–261. DOI: 10.1080/10509670802143680.
Sacks, S. (2008). Brief overview of screening and assessment for co-occurring disorders. International
Journal of Mental Health and Addiction, 6(1), 7–19. DOI: 10.1007/s11469-007-9098-0.
Sacks, S., Banks, S., McKendrick, K., & Sacks, J. Y. (2008a). Modified therapeutic community for cooccurring disorders: A summary of four studies. Journal of Substance Abuse Treatment, Special Issue:
Recent Advances in Research on the Treatment of Co-Occurring Disorders, S. Sacks, R. Chandler, & J.
Gonzales (Eds.), 34(1), 112–122. DOI: 10.1016/j.jsat.2007.02.008.
Sacks, S., McKendrick, K., Sacks, J. Y., Banks, S., & Harle, M. (2008b). Enhanced outpatient treatment
for co-occurring disorders: Main outcomes. Journal of Substance Abuse Treatment, Special Issue: Recent
Advances in Research on the Treatment of Co-Occurring Disorders, S. Sacks, R. Chandler, & J. Gonzales
(Eds.), 34(1), 48–60. DOI: 10.1016/j.jsat.2007.01.009.
Sacks, S., Melnick, G., Coen, C., Banks, S., Friedmann, P. D., Grella, C., & Knight, K. (2007a).
CJDATS Co-Occurring Disorders Screening Instrument (CODSI) for Mental Disorders (MD): A pilot
study. The Prison Journal, Special Issue: Criminal Justice Drug Abuse Treatment Studies (CJ-DATS), H.K.
Wexler, M. Prendergast, & G. Melnick (Eds.), 87(1), 86–110.
Sacks, S., Melnick, G., Coen, C., Banks, S., Friedmann, P. D., Grella, C., Knight, K., & Zlotnick, C.
(2007b). CJDATS Co-Occurring Disorders Screening Instrument (CODSI) for Mental Disorders
(MD): A validation study. Criminal Justice and Behavior, Special Issue: Offender Needs and Functioning
Assessments, D.D. Simpson & K. Knight (Eds.), 34(9), 1198–1215.
Sacks, S., Sacks, J. Y., & De Leon, G. (1999). Treatment for MICAs: Design and implementation of the
modified TC. Journal of Psychoactive Drugs, (Special Edition), 31(1), 19–30.
Sacks, S., Sacks, J. Y., De Leon, G., Bernhardt, A. I., & Staines, G. L. (1997). Modified therapeutic
community for mentally ill chemical ‘‘abusers’’: Background; influences; program description; preliminary findings. Substance Use and Misuse, 32(9), 1217–1259.
Sacks, S., Sacks, J. Y., McKendrick, K., Banks, S., & Stommel, J. (2004a). Modified TC for MICA
offenders: Crime outcomes. Behavioral Sciences and the Law, 22, 477–501.
Sacks, S., Sacks, J. Y., McKendrick, K., Pearson, F., Banks, S., & Harle, M. (2004b). Outcomes from
a therapeutic community for homeless, addicted mothers and their children. Administration and
Policy in Mental Health and Mental Health Services Research, 31(4), 313–338. DOI: 10.1023/
B:APIH.0000028895.78151.88
Simpson, D. D. (1997) The Texas Christian University HIV/AIDS risk assessment. Retrieved January 11,
2008, from http://www.ibr.tcu.edu/pubs/datacoll/Forms/intake-ara-95.PDF
Simpson, D. D., & Sells, S. B. (1982). Effectiveness of treatment of drug abuse: An overview of the DARP
research program. Advances in Alcohol and Substance Abuse, 2(1), 7–29.
Sullivan, C. J., McKendrick, K., Sacks, S., & Banks, S. M. (2007). Modified TC for MICA offenders:
Substance use outcomes. American Journal of Drug and Alcohol Abuse, 33(6), 823–832.
Copyright # 2008 John Wiley & Sons, Ltd.
Behav. Sci. Law 26: 413–434 (2008)
DOI: 10.1002/bsl
434
J. Y. Sacks et al.
Teplin, L. A., Abram, K. M., & McClelland, T. (1996). Prevalence of psychiatric disorders among
incarcerated women. Archives of General Psychiatry, 53(6), 505–512.
Wanburg, K., & Milkman, H. (1998). Strategies for self-improvement and change: A cognitive behavioral
approach for treatment of the substance abusing offender. Thousand Oaks, CA: Sage–Centre for Interdisciplinary Studies.
Wexler, H. K., Falkin, G. P., & Lipton, D. S. (1990). Outcome evaluation of a prison therapeutic
community for substance abuse treatment. Criminal Justice and Behavior, 17(1), 71–92.
Zweben, J. E., Cohen, J. B., Christian, D., Galloway, G. P., Salinardi, M., Parent, D., Iguchi, M., &
Methamphetamine Treatment Project. (2004). Psychiatric symptoms in methamphetamine users.
American Journal on the Addictions, 31(2), 181–190.
Copyright # 2008 John Wiley & Sons, Ltd.
Behav. Sci. Law 26: 413–434 (2008)
DOI: 10.1002/bsl