Addressing the High Rates of Mental Health Problems and Substance Abuse among Incarcerated Women

Victoria Espinoza, University of New Haven

Photo by Dan Meyers on Unsplash 

During the last five decades, the female offender population in the United States increased by more than 500% (Monazzam & Budd, 2023). Though smaller than the total male offender population, the rate of incarcerated women has remained double the rate of incarcerated men since the 1980s, and some argue this is partly due to the increased criminalization of drug use (Monazzam & Budd, 2023). Female inmates have presented vastly different needs than male inmates; many studies have found incarcerated women have higher rates of mental health issues and a greater likelihood to abuse substances (Haesen et al., 2019; Lynch et al., 2012; Lynch et al., 2013). Screening tools and treatment programs in correctional facilities for mental health and substance abuse have been found to be inadequate at addressing female offenders’ needs, leading to undiagnosed, misdiagnosed, or ineffectively treated mental health and substance abuse issues (Wood, 2019).

This policy brief focuses on how to address the rising mental health and substance abuse rates among incarcerated women, which continue to outpace the rates of incarcerated men. First, the brief will discuss the history of mental illness and substance abuse in female prison and jail populations, and how gendered the approaches have been in the past. Focusing on areas that can be improved, this brief seeks to show screening improvements and integrated mental health and substance abuse programs with a focus on traumatization. Pre-existing approaches are explored and compared to new programs and initiatives that aim to address the issues discussed. In the country with the largest prison population in the world, addressing the needs of one of its most rapidly growing subpopulations is crucial. To illustrate, studies have shown treatment for mental health and substance abuse is highly correlated with successful reentry and lower recidivism risks (Fazel et al., 2016).

Statement of the Issue

Studies have found incarcerated women are more likely to struggle with substance abuse and their mental health than incarcerated men (Haesen et al., 2019; Lynch et al., 2012; Fazel et al., 2016). A 2017 Department of Justice (DOJ) report found female jail inmates were more likely to have a history of mental health issues (66% of females to 35% of males), as well as more likely to have serious psychological stress (Bronson & Berzofsky, 2017). The gendered trend continues for substance and alcohol abuse. A 2021 DOJ report found female inmates at the state level were more likely than male inmates to report drug use during the time of their offense and were more likely to have a substance use disorder in the past 12 months, while at the federal level, female inmates were more likely to report alcohol or substance use at the time of offense (Maruschak & Alper, 2021). Trauma has also been found to be prevalent in female offenders, and often intertwined with mental health and substance abuse disorders (Wood, 2019).

Efforts to provide mental health and substance abuse treatment have been criticized for having limited effects on incarcerated women compared to incarcerated men. Experts have argued for a gender-specific approach, improved screening assessments, programs that integrate substance abuse treatment with mental health treatment, and a focus on traumatization (Lynch et al., 2012). Gender-specific, trauma focused and integrated mental health and substance abuse screening tools and treatment programs offer attempts at solving some of these issues. Federal and state penitentiary facilities could work to implement these initiatives and offer incarcerated women improved resources. Government grants could also sponsor more validation studies of these programs to measure their effectiveness. 

Background of the Problem

Numerous studies on the female incarceration population have found a prevalence of mental health and substance abuse issues among inmates, considerably outpacing male inmates. A DOJ study of urban and rural jails found female inmates reported higher rates of mental illness than male inmates (Lynch et al., 2013). A study of jail populations in the Northeast of the United States found the percentage of incarcerated women struggling with mental health issues was double the percentage of incarcerated men (​​Steadman et al., 2009). Across the pond, a UK-based study found that both current and pre-existing needs for mental health treatment were higher among female prisoners than males (Tyler et al., 2019). A 2006 DOJ report found female inmates presented more mental health issues than male inmates; specifically, 76% of female jail inmates compared to 63% of male jail inmates (James & Glaze, 2006). Additionally, female state prison inmates (75%) were more likely to have substance abuse issues, compared to male state prison inmates (54%). Non-government reports have also detailed the gender disparity of mental health issues in incarcerated populations, noting that 1 in 5 incarcerated women struggle with a mental disorder compared to 1 in 7 incarcerated men (Villa, 2017).

Empirical research also shows drug use and substance abuse is frequent among incarcerated women, with one study of federal inmates reporting women had higher reported drug use than male inmates (Langan & Pelissier, 2001). Fazel and colleagues (2016) found drug misuse was more regularly reported in female inmates than male inmates. Further, studies have outlined the comorbidity of substance abuse and mental health struggles in inmate populations. One meta-analysis of 34 studies conducted between 1980 and 2021 focused on mental health and substance abuse outcomes in prison populations found substance abuse and mental health were highly connected —and that the rate of comorbid disorders was about 20 times higher than general populations (Baranyi et al., 2022). Dual disorders have been found to be more prevalent in women than men, associated with more serious criminal backgrounds, and found to worsen the diagnosis or severity of the illness (Baranyi et al., 2022). Wolff and colleagues (2010) found 50% of incarcerated women who struggled with mental health had issues with addiction.

In addition to substance abuse and mental health issues, female offender populations also show high rates of prior victimization and prior traumatization. Research has shown a high rate of trauma in multiple age groups of female offenders (DeHart et al., 2013), while another study found 98% of female inmates had prior traumatization (Green et al., 2005). One study found 83% of the female prisoners had a history of trauma that significantly contributed to their substance use disorder diagnosis (Green et al., 2016). Another study found more than 85% of women in the sample who met a form of Post-Traumatic Stress Disorder (PTSD) criteria also met the criteria for substance abuse disorder (Wolff et al., 2010). Wood (2019) argued past traumatic experiences can be a pathway to criminal behavior.

The gendered struggles facing incarcerated women have caused many scholars to argue for a more specific approach when it comes to rehabilitation and treatment of female offenders versus male offenders. Wood (2019) argued the complexity of female needs require different treatment than male needs in offender populations, due to the individual life challenges they face. A study of female inmates awaiting release found nearly 70% suffered from a mental illness; there was a significant association between mental illness and prior traumatization, with 88% having a traumatic exposure, including 74% experiencing childhood sexual or physical trauma (Wolff et al., 2011). These types of trauma-related mental health issues are frequent in incarcerated women but are less frequent in incarcerated men. 

Screening

Studies of prison and jail populations have found mental health screening to increase the likelihood of positive outcomes, as these populations have such a high prevalence of mental health issues (Tyler et al., 2019; Martin et al., 2016; Pimlott Kubiak et al., 2010). Pimlott Kubiak and colleagues (2010) stressed the need for improved screening measures in the female inmate population, as many suffer from non or misidentification of their mental health or substance abuse issues. A UK-based study found gendered differences in the sensitivity of screening tools, citing a need for better results for female inmates (Tyler et al., 2019). Both researchers and inmates echo the need for screening measures. A qualitative study of incarcerated women with a desire for trauma-informed care found a consensus in a desire for improved screening measures (Matheson et al., 2015).

U.S. jails and prisons do offer a variety of screening approaches for mental health and substance abuse. The Brief Jail Mental Health Screen (BJMHS) is a mental health screening assessment used in some jails; one study found the tool was able to correctly identify and classify mental health issues for more than half of all participants (Steadman et al., 2005). However, BJMHS was found to be significantly less effective at identifying symptoms of mental illness among female participants (Steadman et al., 2005). Not only did the BJMHS miss nearly 35% of women with symptoms, but it also incorrectly identified symptoms in 45% of women. Nevertheless, Steadman and colleagues (2005) still identified BJMHS as one of the most effective screenings compared to others used in jails for female populations. BJMHS only concerns a mental health screening tool; thus, it does not address the issue with substance abuse.

Comprehensive Addictions and Psychological Evaluation (CAAPE) is another screening tool designed for inmates, one which incorporates both mental health and substance abuse (Carkin et al., 2018). Acknowledging the comorbidity of mental health issues and substance abuse, CAAPE was designed to address both, and studies have validated the predictive capability of the tool (Carkin et al., 2018). One study found CAAPE to be effective at identifying mental disorders and substance abuse, though more effective with the former than the latter (Carkin et al., 2018). Another study found the CAAPE did well at identifying different levels of mental health needs and severities (Proctor & Hoffmann, 2012). However, both of these studies evaluated exclusively with male prison populations, offering no insight as to their effectiveness for female inmate populations.

Treatment Programs

In addition to screening, prisons and jails offer different types of mental health treatment programs to inmates. A 2017 meta-analysis of 37 studies on different mental health treatment programs for incarcerated individuals found cognitive behavioral based programs were moderately successful in improving the mental wellbeing of incarcerated individuals, with an effect size of .50 (Yoon et al., 2017). Study outcomes included depression, trauma, psychopathology, and hostility and anger, and researchers assessed the effectiveness of music therapy, art therapy, self-help treatment programs, mindfulness-based therapy, dialectical behavior therapy, and cognitive behavioral therapy. Again, results showed cognitive behavioral therapy programs had the strongest results, but the practical significance was argued to be moderate (Yoon et al., 2017). The National Institute of Corrections has acknowledged the effectiveness of cognitive behavioral therapy for offenders and its required inclusion in treatment (Clark, 2010). Yet, government reports show these types of programs are not actually the prevailing approach for inmates struggling with mental health issues (James & Glaze, 2006). The most recent DOJ report on the mental health of state and federal inmates shows the most common treatment for mental health issues at the state and federal level is prescription medication, ​​with 27% of state inmates, 19% of federal inmates, and 15% of jail inmates reporting being prescribed medication due to a mental health issue (James & Glaze, 2006). The next most common treatment was mental health therapies, including cognitive behavioral therapy.

Shifting to substance abuse treatment programs for incarcerated populations, the DOJ also offers treatment programs for dependency and abuse of substances. A 2019 report found 90% of female inmates were enrolled in specialty programs for drug or alcohol dependency (Maruschak & Buehler, 2019). One program is the Residential Drug Abuse Program (RDAP). This program boasts the most effective results for recidivism reduction and was expanded to be used for female inmates (Pelissier et al., 2003). However, research into the effectiveness of this program from a gendered lens found RDAP only reached statistical significance with the male inmate population, and the study also highlighted differences in characteristic traits for male versus female offenders that could affect the success of treatment (Pelissier et al., 2003). This continues the theme of gendered differences in treatment outcomes for incarcerated women.

Fazel and colleagues (2016) argued that limited research from government entities makes it difficult to determine the specifics of mental health and substance abuse programs in correctional facilities. Research on correctional programs that address the comorbidity of mental health and substance abuse was scarce for this policy brief, but research that addressed each independently was not (Maruschak & Buehler, 2019; James & Glaze, 2006).

Policy Options

Based on the existing research and established policies, this brief offers two policy options. The first is to offer improved screening measures that are brief, easily accessible to those administering, gendered, and standardized. As previously discussed, current screening procedures are not standardized in all prisons and jails in the U.S. (Steadman et al., 2005), but tools have still been developed, and reports have been validated for their accuracy (Carkin et al., 2018; Steadman et al., 2005). However, these current screening tools showed serious gendered limitations for female inmates. Therefore, this option suggests the use of instruments developed by the Texas Christian University (TCU) to screen for both mental health issues and substance abuse risk (Simpson et al., 2012). TCU tools include HLTHForm, a mental health measure using some Kessler Psychological Distress Scale items, and TCUDS II is a drug use severity measure which follows the DSM-IV criteria for drug use (Rowan-Szal et al., 2012). These instruments have been found to be effective at identifying mental health and substance abuse in two female prison units (Rowan-Szal et al., 2012). TRMAForm, a trauma measure that utilizes questions from the PTSD Checklist, is another beneficial component of TCU’s approach.

Rowan-Szal and colleagues (2012) argue the introduction of more effective screening measures with a specific eye on trauma would improve jail and prison services. One study found that when incarcerated women had trauma or mental health issues that went unrecognized, chances of self-harm and suicidal tendencies increased (Ariga et al., 2008). Incarcerated women have also tried to advocate themselves for improved screening measures, particularly with a focus on trauma. Matheson and colleagues (2015) interviewed 36 incarcerated women and found a high rate of prior traumatization among participants. The women in the study consistently argued for improved screening measures to help identify trauma at both intake and before release, to help improve their chances of successful treatment, as well as ensure more women with mental health issues or substance abuse issues do not miss the opportunity for treatment (Matheson et al., 2015).

The second policy option is to offer an integrated, gender specific program with a focus on trauma to all incarcerated women. As previously discussed, mental health and substance abuse treatment programs in corrections are complex and flawed. Despite research showing the effectiveness of cognitive behavioral programs for mental health and substance abuse treatment, reports showed that these methods are not the most utilized practices in the jails and prisons across the U.S. (Yoon et al., 2017; James & Glaze, 2006). Treatment programs heralded as a success have been shown to be far less effective for female inmates, underscoring a need for gender specific treatment (Pelissier et al., 2003). In addition, current treatment programs show a lack of dual approach for mental health alongside substance abuse. Female inmates expressed prison services focused disproportionality on substance abuse, and did not commit enough resources for traumatic experiences, which they argued led them to substance abuse originally (Lynch et al., 2012). Matheson and colleagues (2015) found the same sentiment among female participants; more focus should be on healing from prior traumatization, as that was seen as the root of substance use and abuse, and that the standard treatment lacked an opportunity to treat traumatization.

Programs have been developed in response to the high rates of substance abuse and mental health issues within the female incarceration population, with a more integrated approach towards mental health and substance abuse, and a focus on female participants. One study of female inmates from 9 different jails in the United States found more than two thirds of inmates had experienced a traumatic event that had contributed to a substance use disorder (Green et al., 2016). This option would suggest using Seeking Safety, an evidence-based cognitive behavioral intervention program, with an integrated approach for substance abuse and mental health issues (Brown et al., 2007). Seeking Safety has been empirically validated to successfully improve the mental health and substance use of female participants (Brown et al., 2007).

Policy Option 1

One empirical study of TCU’s tools, with a sample size of about 1,400 female offenders, found the assessments were effective at identifying mental health issues including PTSD, as well as drug use severity, as well as identifying cut off scores to assess a range of severity in symptoms (Rowan-Szal et al., 2012). In addition, these tools offer a measurement for trauma. Researchers have argued for a more specific focus on trauma during intake and treatment for incarcerated women, as the number of female offenders with prior victimization and traumatization rises and risks of undiagnosed trauma include self-harm and suicide (Lynch et al., 2012; Green et al., 2005; Ariga et al., 2008). Furthermore, incarcerated women with past-traumatic experiences can develop complex and unique types of trauma that potentially go unrecognized during screenings and assessments. Therefore, a tool that can identify a range of symptoms is crucial (Lynch et al., 2012). The trauma specific TCU tool is an additional strength of this policy brief. Rowan-Szal and colleagues (2012) found traumatic disorders like PTSD were successfully identified with the TCU screening tools.

As discussed, experts argue the mental health and substance abuse needs of incarcerated women often go undetected. Both mental health and substance abuse issues are strong predictors of recidivism (Pimlott Kubiak et al., 2010). Thus, implementing a standard screening approach would be a worthwhile initiative to address the issue of this policy brief. Another strength is in the cost calculations. TCU tools were all designed to be brief and easily accessible, so training corrections staff on using these tools would not be overly intensive, costly, or lengthy.

One concern with this policy option is the limited research on TCU’s tools, with only one replication study to Rowan-Szal and colleagues (2012) work on the validity of the screening measures. Simpson and colleagues (2012) assessed the effectiveness of TCU’s tools with a sample of over 5,000 inmates and found support for the use of the tools to screen for mental health and substance abuse disorders. Unfortunately, those are the only two validation studies to support this tool. Without additional evaluations of these screening instruments, it is ambiguous how effective they would be and how productive this policy suggestion would be to address the rising rates of substance abuse and mental health issues in the female offender population.

Another disadvantage regarding the sample populations used to validate these tools is the demographics. White female inmates were the dominant ethnic group in both studies, highlighting a gap in representation for women of color, which could underscore a less effective tool for those women (Simpson et al., 2012; Rowan-Szal et al., 2012). Both samples also had a mean age around 35, meaning this option may not be effective for juvenile female offenders.

Policy Option 2

Seeking Safety, an evidence-based cognitive behavioral intervention program, offers an integrated approach for substance abuse and mental health issues including trauma (Brown et al., 2007). Seeking Safety has been evaluated specifically for female offenders, and its aim is to teach participants coping skills to attain safety in their lives. This includes resources on both trauma and substance abuse. Gatz and colleagues (2007) researched the effectiveness of Seeking Safety within a female only offender population and found when compared to a control group (which did not have a trauma focused aspect), the Seeking Safety treatment group had significant improvements on PTSD symptoms and coping skills.

One concern with Seeking Safety is in the mixed results of treatment outcomes in more than one study. In one study, the mean scores for alcohol and drug abuse improvement were considerably low, showing a less powerful effect on substance abuse than trauma (Gatz et al., 2007). Another study focused on women released from prison also found Seeking Safety did not improve alcohol abuse in the treatment group (Zlotnick et al., 2009). Looking at trauma outcomes, evidence showed six months post-release, more than half of both the control group and the treatment group had reported remissions in PTSD symptoms (Zlotnick et al., 2009). A multisite study also found lackluster results from Seeking Safety, with evidence showing the program was not more effective than treatment as usual for women with PTSD and substance abuse disorder (​​Schäfer et al., 2019). Results were stronger when either issue was isolated; those with both substance abuse issues and PTSD, a specific mental health issue, did not see an improvement with Seeking Safety.

If these results continue, it could lead to potentially unbalanced treatment for mental health and substance abuse, an outcome that studies show is linked to recidivism and worsening symptoms (Pimlott Kubiak et al., 2010). Another potential disadvantage of this policy recommendation is the cost. Implementing a comprehensive program in correctional facilities across the United States is costly and would require a large number of resources.

Recommendation

Many studies have found incarcerated women face higher rates of mental health issues, including PTSD and prior traumatization, and substance abuse than incarcerated men. As the female inmate population has continued to grow, more incarcerated women are struggling with mental health issues and substance abuse, with inadequate resources to rehabilitate them while they are incarcerated (Villa, 2017). Current strategies and programs have been criticized for their shortcomings, including the non-gendered approach to mental health and substance abuse, the absence of trauma-informed resources, and weak screening tools that are failing to identify women with mental health or substance abuse issues.

This brief recommends Option 2, to require the option of participating in the Seeking Safety treatment for women in jail and prison populations. This strategy addresses many of the issues outlined in this brief, starting with the need for a gender-specific approach. Many argue traditional treatment methods have been validated with male dominated inmate populations, and that this has led to gaps in effectiveness for female inmates (Wolff et al., 2010). Additionally, female treatment needs have been found to be specific and unique; another reason treatment programs for female inmates need to be assessed for female participants (Wood, 2019). Seeking Safety has been evaluated in female specific inmate populations, and found successful treatment outcomes (Gatz et al., 2007; Schäfer et al., 2019).

Another issue experts say is providing ineffective care is the isolated treatment for mental health and substance abuse, as research shows both a high rate of comorbidity between mental health and substance abuse disorders in prison populations, combined with a preference among inmates for an integrated approach that acknowledges how both issues are connected (Baranyi et al., 2022; Matheson et al., 2015; Lynch et al., 2012). Validation studies have concluded Seeking Safety showed improvement in mental health and substance abuse outcomes in female inmate populations (Gatz et al., 2007; Schäfer et al., 2019).

Finally, researchers have found female offenders share high rates of prior traumatization and are left untreated in which those issues can lead to serious outcomes including suicide (Ariga et al., 2008). Additionally, incarcerated women argued for mental health treatment that focuses on healing from prior traumatization (Matheson et al., 2015). Participants of Seeking Safety were found to have significant reductions of trauma-related symptoms, including PTSD (Najavits, 2007).

Annotated Bibliography

Ariga, M., Uehara, T., Takeuchi, K., Ishige, Y., Nakano, R., & Mikuni, M. (2008). Trauma exposure and posttraumatic stress disorder in delinquent female adolescents. Journal of Child Psychology and Psychiatry, 49(1), 79-87.

This empirical study examines the prevalence of trauma exposure and posttraumatic stress disorder (PTSD) among delinquent juvenile females. Results showed that 95.1% of the participants reported experiencing at least one traumatic event in their lifetime, with physical abuse and sexual abuse being the most commonly reported events. Additionally, 40.8% of the participants met the criteria for a diagnosis of PTSD, and PTSD symptoms were significantly associated with a history of physical abuse, sexual abuse, and a greater number of traumatic events experienced.

Baranyi, G., Fazel, S., Langerfeldt, S. D., & Mundt, A. P. (2022). The prevalence of comorbid serious mental illnesses and substance use disorders in prison populations: a systematic review and meta-analysis. The Lancet Public Health, 7(6), e557-e568.

This meta-analysis used 34 studies that reported on dual disorders of mental health and substance abuse and found about half of all participants in the studies struggled with comorbidity of mental health and substance abuse disorders. This report also highlights the added risks associated with the comorbidity of mental health and substance abuse disorders, as well as the significant increase in inmates with comorbidity issues compared to the general public.

Brown, V. B., Najavits, L. M., Cadiz, S., Finkelstein, N., Heckman, J. P., & Rechberger, E. (2007). Implementing an evidence-based practice: Seeking Safety group. Journal of Psychoactive Drugs, 39(3), 231-240.

This evaluation study of Seeking Safety, an evidence-based program for mental health and substance abuse, used both participants in the program and clinicians who administered the treatment in their research (N=189). It includes information on Seeking Safety. Researchers found both groups were satisfied with the program, however this study acknowledged the attrition rate of participants was a particular limitation. Another limitation mentioned was that all sites already had experienced background in substance abuse treatment, and they were unsure if this contributed to the success of the program.

Bronson, J., & Berzofsky, M. (2017). Indicators of mental health problems reported by prisoners and jail inmates, 2011–12. Bureau of Justice Statistics, (Special Issue), 1-16.

This Bureau of Justice Statistics report from the DOJ outlines the mental health issues of federal and state inmates between 2011 and 2012. The findings show a large proportion of inmate struggle with mental health issues. The Kessler 6 (K6) nonspecific psychological distress scale was used to determine the mental health of inmates. Results show mental health issues were more prevalent in jail populations versus prison populations, and found female inmates had higher rates of mental health issues in a variety of circumstances including both prison and jail.

Carkin, D., & Tracy, P. (2018). Validating a screening instrument for co-occurring disorders in a sample of jail inmates. Journal of Law and Criminal Justice, 6(1), 9-20.

This empirical study examined the validity of CAAPE, a screening tool for mental health. The sample population included both male and female jail inmates (N=426). Results showed the screening tool had good sensitivity and specificity among the sample of inmates, and that the prevalence of comorbidity for mental health disorders was high. Researchers concluded CAAPE can be an effective tool for identifying mental health disorders among jail inmates.

Clark, P. (2010) Preventing future crime with cognitive behavioral therapy. National Institute of Justice. Retrieved at https://nij.ojp.gov/topics/articles/preventing-future-crime-cognitive-behavioral-therapy

This article discusses the benefits of cognitive behavioral therapy, which focuses on identifying and changing negative thought patterns and behaviors that contribute to criminal behavior. The author argues CBT can be effective in reducing recidivism because it helps offenders to develop coping skills, problem-solving strategies, and prosocial attitudes and behaviors.

DeHart, D., Lynch, S., Belknap, J., Dass-Brailsford, P., & Green, B. (2013). Life history models of female offending: The roles of serious mental illness and trauma in women’s pathways to jail. Psychology of Women Quarterly, 38(1), 138-151.

This empirical study looked at criminal pathways for women in jail, utilizing both quantitative and qualitative data. The quantitative research included structured interviews (N=491) and the qualitative research used life history interviews (N=115). Researchers found a high prevalence of mental health issues and trauma among participants, and a high likelihood of victimization, including intimate partner violence and witnessing violence, for participants with more elevated mental health issues. 

Fazel, S., Hayes, A. J., Bartellas, K., Clerici, M., & Trestman, R. (2016). Mental health of prisoners: Prevalence, adverse outcomes, and interventions. The Lancet Psychiatry, 3(9), 871-881.

This systematic review of mental health issues and initiatives in prisoner populations used one section to focus primarily on the results of women in prison. The report addresses the different complexities in female inmates and acknowledges that most trauma-based resources for women did not report statistically significant findings. Female inmates were also found to have higher rates of drug misuse. 

Gatz, M., Brown, V., Hennigan, K., Rechberger, E., O'Keefe, M., Rose, T., & Bjelajac, P. (2007). Effectiveness of an integrated, trauma‐informed approach to treating women with co‐occurring disorders and histories of trauma: The Los Angeles site experience. Journal of Community Psychology, 35(7), 863-878.

This empirical study examined the effectiveness of an integrated, trauma-informed approach to treating women with co-occurring disorders and histories of trauma. Researchers found that participants who completed the integrated, trauma-informed treatment had significant reductions in substance use, mental health symptoms, and trauma symptoms. Additionally, participants reported high levels of satisfaction with the treatment approach.

Green, B. L., Miranda, J., Daroowalla, A., & Siddique, J. (2005). Trauma exposure, mental health functioning, and program needs of women in jail. Crime & Delinquency, 51(1), 133-151.

This female focused empirical study (N=100) looked at jail inmates for trauma exposure. Researchers found the majority of participants had previous trauma exposure, issues with alcohol or substance abuse, and mental health issues. Results showed participants desired treatment programs that focused on prior traumatization and victimization.

Green, B. L., Dass-Brailsford, P., Hurtado de Mendoza, A., Mete, M., Lynch, S. M., DeHart, D. D., & Belknap, J. (2016). Trauma experiences and mental health among incarcerated women. Psychological Trauma: Theory, Research, Practice, and Policy, 8(4), 455.

This empirical study collected data from women in 9 prisons throughout the United States (N=464). Researchers interviewed participants for trauma exposure and psychiatric disorders, and found family dysfunction, interpersonal violence, and external events were related to trauma. Women who experienced any of these events were more likely to suffer from mental health disorders.

Haesen, S., Merkt, H., Imber, A., Elger, B., & Wangmo, T. (2019). Substance use and other mental health disorders among older prisoners. International Journal of Law and Psychiatry, 62, 20-31.

This systematic review of the literature focused on substance abuse and mental health issues in older prisoner populations, looking at a total of 17 research studies. Researchers found the majority of the studies focused on male inmate populations, confirming a greater need for focus on female inmate populations. Results showed older inmates had even higher risks of substance abuse and mental health issues.

James, D. J., & Glaze, L. E. (2006). Mental health problems of prison and jail inmates. Department of Justice. Retrieved at https://bjs.ojp.gov/content/pub/pdf/mhppji.pdf

This Bureau of Justice statistics special report highlights the mental wellbeing of local jail and both state and federal prison inmates. The data was collected through personal interviews between 2002 and 2004. Mental health was measured in two ways: recent history or symptoms of a mental health issue. The report found more than 50% of inmates struggled with mental health, and that female offenders presented higher rates of mental health issues than male inmates. It also covers a variety of other demographic breakdowns.

Langan, N. P., & Pelissier, B. M. (2001). Gender differences among prisoners in drug treatment. Journal of Substance Abuse, 13(3), 291-301.

This quantitative study of 1,326 male and 318 female federal inmates participating in a substance abuse treatment program found gender played a major role in outcome. Female inmates in the study were found to have higher rates of drug use, found to use harder drugs than male inmates, and found to have different motivations for their drug use than male inmates. Women were also more likely to have prior traumatization. Researchers concluded support for the idea of gendered treatment programs.

Lynch, S. M., Heath, N. M., Mathews, K. C., & Cepeda, G. J. (2012). Seeking safety: an intervention for trauma-exposed incarcerated women? Journal of Trauma & Dissociation, 13(1), 88-101.

This validation study of Seeking Safety used a minimum- and maximum-security level prison in the Northeast of the United States and focused on a female inmate population (N=114). The average age of participants was 35, and participants had to have a prior history of traumatization, a history of substance abuse and moderate PTSD symptoms. Results showed Seeking Safety participants had decreased PTSD symptoms, which maintained longer than the control group, as well as improved coping strategies. Drug outcomes were less significant than mental health outcomes.

Lynch, S. M., DeHart, D. D., Belknap, J., & Green, B. L. (2013). Women’s pathways to jail: Examining mental health, trauma, and substance use. Bureau of Justice Assistance, U.S. Department of Justice.

This DOJ Bureau of Justice policy brief studied how mental health, substance abuse and trauma are pathways to incarceration for women. This mixed method study used participants from rural and urban jails, using structured interviews for quantitative research (N = 491), and life history calendar interviews for qualitative research (N = 115). Results showed high rates of substance abuse, trauma, and mental health issues in the sample. Additionally, women’s health care issues require complex treatment. 

Maruschak, L. M. & Buehler, E. D. (2019) Census of state and federal adult correctional facilities, 2019 – statistical tables. U.S. Department of Justice. Retrieved at https://bjs.ojp.gov/content/pub/pdf/csfacf19st.pdf

This DOJ report provides data on the number and characteristics of adult correctional facilities in the United States, including prisons, jails, and community-based correctional facilities. It provides information on the characteristics of the inmate population in adult correctional facilities, including gender, race, and age.

Maruschak & Alper (2021) Alcohol and drug use and treatment reported by prisoners. U.S. Department of Justice Bureau of Justice Statistics. Retrieved at https://bjs.ojp.gov/sites/g/files/xyckuh236/files/media/document/adutrpspi16st.pdf

This DOJ report from the Bureau of Justice Statistics used a survey of federal and state inmates from 2016 (N= 1,421,700). The self-report survey detailed drug and alcohol use and found nearly 40% of inmates reported using drugs and 30% reported alcohol use. The report breaks down demographics of inmates, and shows differences by race, age, gender and prison or jail.

Martin, M. S., Potter, B. K., Crocker, A. G., Wells, G. A., & Colman, I. (2016). Yield and efficiency of mental health screening: A comparison of screening protocols at intake to prison. PLoS One, 11(5), e0154106.

This empirical study evaluated screening tools for mental health issues in Canadian prisons. The study focused only on male inmates (N=467) and compared inmates who participated in the screening program with those who did not. Results showed screening is far more effective in populations with a high prevalence of mental health issues, like correctional facilities, and that more studies need to be done evaluating the effectiveness of different screening tools.

Matheson, F. I., Brazil, A., Doherty, S., & Forrester, P. (2015). A call for help: Women offenders' reflections on trauma care. Women & Criminal Justice, 25(4), 241-255.

This empirical study used a qualitative approach to assess trauma in incarcerated women (N=33). Results found that trauma was a common experience among the women in the sample, with almost all participants reporting a history of trauma. However, many of the women faced barriers to accessing trauma care within the criminal justice system. These barriers included a lack of available services, long wait times, and a lack of trust in service providers.

Monazzam, N. and Budd, K. M (2023, April 3) Incarcerated Women and Girls. The Sentencing Project. Retrieved at https://www.sentencingproject.org/fact-sheet/incarcerated-women-and-girls/

This study from The Sentencing Project, a nonprofit organization, covers the trend of increasing rates of incarcerated women in the United States, and the implications of that growth. Using data from the Department of Justice, the report highlights the demographics of the female offender population, and which groups have been disproportionately affected by the accelerated growth.

Proctor, S. L., & Hoffmann, N. G. (2012). Identifying patterns of co-occurring substance use disorders and mental illness in a jail population. Addiction Research & Theory, 20(6), 492-503.

This empirical study researched substance use and mental health of male and female jail inmates (N=300) using self-report data. Results showed that the prevalence of substance abuse disorders and mental illness was high among the jail population, with over 70% of the sample reporting a history of substance abuse and over 60% reporting a history of mental illness. Researchers also found that certain patterns of co-occurring substance abuse disorders and mental illness were more common than others.

Pelissier, B. M., Camp, S. D., Gaes, G. G., Saylor, W. G., & Rhodes, W. (2003). Gender differences in outcomes from prison-based residential treatment. Journal of Substance Abuse Treatment, 24(2), 149-160.

This empirical study of male and female prison inmates focused on how gender affects post-release outcomes after substance abuse treatment (male N=1,842 and female N=473). Participants were in residential drug abuse programs at maximum, medium and minimum facilities. Results found women had more life problems than men, and improvement in drug abuse for women in the treatment group was not statistically significant (it was for men). The researchers argued the results suggest there could be a gendered connection between mental health and drug treatment outcomes, and that more research on specific gender studies is needed.

Pimlott Kubiak, S., Beeble, M. L., & Bybee, D. (2010). Testing the validity of the K6 in detecting major depression and PTSD among jailed women. Criminal Justice and Behavior, 37(1), 64-80.

This empirical research examines the effectiveness of the K6 screening tool in identifying major depression and PTSD in incarcerated women. Female jail inmates in Midwestern states (N=245) were interviewed to see if the K6 was effective at detecting any disorders they had. Results showed the tool performed well and could be used as a tool going forward for mental health screening of female offenders.

Rowan-Szal, G. A., Joe, G. W., Bartholomew, N. G., Pankow, J., & Simpson, D. D. (2012). Brief trauma and mental health assessments for female offenders in addiction treatment. Journal of offender rehabilitation, 51(1-2), 57-77.

This empirical study explores the development and implementation of brief trauma and mental health assessments for female offenders in addiction treatment settings. Results show these tools can be useful for addiction treatment providers working with female offenders, as they can quickly identify clients who may benefit from further assessment and treatment for trauma and mental health issues. They note that the assessments can also be useful for researchers who need to collect data on trauma and mental health among female offenders in addiction treatment settings.

Schäfer, I., Lotzin, A., Hiller, P., Sehner, S., Driessen, M., Hillemacher, T. & Grundmann, J. (2019). A multisite randomized controlled trial of Seeking Safety vs. Relapse Prevention Training for women with co-occurring posttraumatic stress disorder and substance use disorders. European Journal of Psychotraumatology, 10(1), 1577092.

This empirical research compared the effectiveness of Seeking Safety (SS) for women with co-occurring PTSD and substance use disorders (N=179). Results indicated that SS was associated with significant improvements in PTSD symptoms, substance use, and depressive symptoms. However, there were no significant differences between the two treatments in terms of treatment outcomes.

Simpson, D. D., Joe, G. W., Knight, K., Rowan-Szal, G. A., & Gray, J. S. (2012). Texas Christian University (TCU) short forms for assessing client needs and functioning in addiction treatment. Journal of Offender Rehabilitation, 51(1-2), 34-56.

This empirical study discusses the development and use of short forms of the Texas Christian University (TCU) instrument in addiction treatment settings. Results suggest that the TCU Short Forms can be a useful tool for addiction treatment providers, as they can provide a comprehensive assessment of clients' needs and functioning in a shorter amount of time. They also note that the Short Forms can be useful for researchers who need to collect data on clients' needs and functioning in addiction treatment settings.

Steadman, H. J., Scott, J. E., Osher, F., Agnese, T. K., & Robbins, P. C. (2005). Validation of the brief jail mental health screen. Psychiatric Services, 56(7), 816-822.

This empirical study of incarcerated populations in New York and Maryland (N =10,330) was a validation of Brief Jail Mental Health Screen, a mental health screening instrument used in jails. Researchers were provided support of the screening tools’ effectiveness for male inmates, but not females. In fact, evidence showed a high rate of false negatives for female participants in the study.

​​Steadman, H.J., Osher, F.C., Robbins, P.C., Case, B., and Samuels, S. (2009). Prevalence of serious mental illness among jail inmates. Psychiatric Services, 60 (6), 761–765.

This empirical study used incarcerated populations from four jails in New York and Maryland to observe rates of mental health issues in female and male populations. Data was collected between 2002 and 2006, and mental health issues were measured with the DMSI-IV. Results found mental health issues were twice as prevalent in female jail inmates, with 31% reporting a serious mental illness and only 14.5% of male jail inmates.

Tyler, N., Miles, H. L., Karadag, B., & Rogers, G. (2019). An updated picture of the mental health needs of male and female prisoners in the UK: prevalence, comorbidity, and gender differences. Social Psychiatry and Psychiatric Epidemiology, 54, 1143-1152.

This UK based empirical study looked at 13 prisons across England, with both female and male populations (N=469), to determine the mental health needs of inmates. Participants were screened for mental disorders, personality disorder, and substance misuse, and results found a high rate of mental health disorders among participants. Additionally, comorbidity of mental disorders was found in a large number of participants, and women were found to have higher rates than men.

Villa, M. (2017) The Mental health crisis facing women in prison. The Marshall Project. Retrieved at https://www.themarshallproject.org/2017/06/22/the-mental-health-crisis-facing-women-in-prison

This report comes from the Marshall Project, a nonprofit organization, focused on criminal justice research. It highlights the disparities for men and women while incarcerated, specifically with mental health treatment. The study uses a DOJ survey of inmates between 2011 and 2012, and reports that mental health services are lacking for inmates of color as well as female inmates.

Wolff, N., Vazquez, R., Frueh, B. C., Shi, J., Schumann, B. E., & Gerardi, D. (2010). Traumatic event exposure and behavioral health disorders among incarcerated females self-referred to treatment. Psychological Injury and Law, 3, 155-163.

This 2010 quantitative empirical study of incarcerated women (N= 196) focused on the mental health of participants, as they enrolled in an integrated, trauma-based treatment program. Results showed participants had high rates of sexual victimization, PTSD, substance, and alcohol abuse. Traumatic events were found to be extremely prevalent among participants. Researchers argued traumatic events were highly correlated with mental health issues among the incarcerated women in the study. PTSD was found to be strongly associated with substance abuse disorders.

Wood, R. (2019). The Trauma-related mental health issues of female prisoners: The Need for trauma-specific intervention. Malmö University.

This literary review analyzed the results of eight studies that focused on the mental health issues and needs of incarcerated women. Findings included a high rate of missed and misdiagnosed trauma-related mental health, particularly PTSD, as well as a common theme among inmates that treatment focused too much on substance abuse. The researcher concluded a lack of effective screening measures for complex mental health issues, especially when connected to trauma.

Yoon, I. A., Slade, K., & Fazel, S. (2017). Outcomes of psychological therapies for prisoners with mental health problems: A systematic review and meta-analysis. Journal of Consulting and Clinical Psychology, 85(8), 783.

This meta-analysis reported on the effectiveness of psychological therapies for prisoners with mental health problems, using 20 different studies. Research showed psychological therapies were effective in reducing symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD) among prisoners with mental health problems. Authors suggested treatments such as cognitive-behavioral therapy and mindfulness-based interventions can be effective in improving mental health outcomes for prisoners with mental health problems.

Zlotnick, C., Johnson, J., & Najavits, L. M. (2009). Randomized controlled pilot study of cognitive-behavioral therapy in a sample of incarcerated women with substance use disorder and PTSD. Behavior Therapy, 40(4), 325-336.

This empirical, quantitative study examined the effectiveness of cognitive-behavioral therapy (CBT) for incarcerated women with co-occurring substance use disorder and posttraumatic stress disorder (PTSD). Results indicated that, compared to the control group, the CBT group showed greater reductions in PTSD symptoms, substance use, and depressive symptoms. These improvements were maintained at the three-month follow-up assessment. These findings suggest that CBT may be an effective treatment for incarcerated women with co-occurring substance use disorder and PTSD.