The pilot study findings were predominantly in the hypothesized direction, with GRT participants showing significantly more success on parole compared with the standard TC treatment group. Although both treatment groups generally showed improvement in self-reported measured outcomes over time, the GRT group had significantly greater reductions in drug use over time. Official records data also revealed important differences in outcomes. The GRT participants voluntarily remained in aftercare treatment for a longer period of time and were less likely to be reincarcerated within 12 months of parole, than those in the standard TC treatment group. Abstinence and time in aftercare treatment has been consistently found to be associated with positive outcomes for offenders, specifically reductions in reincarceration (Burdon, Messina, & Prendergast, 2004
; Messina et al., 2006
). Reductions in reincarceration are of utmost importance for CDCR, especially with the current state of prison overcrowding in California (CDCR, 2007
It is possible that the GRT milieu, curricula, and trauma-informed materials enhanced the overall treatment satisfaction of the participants, compared to those in the standard treatment, underlying the difference in the observed treatment outcomes. In fact, qualitative findings showed that the GRT participants were extremely invested and satisfied with their treatment (especially session topics regarding intimate partners, family roles, and trauma histories), felt supported by other group members, and promoted continued use of these materials and protocols in the prison (Calhoun, Messina, & Cartier, under review). Greenfield and associates (2007)
contend that a GRT environment affords an increased sense of comfort and safety for women so that they more openly share issues regarding their substance abuse. This may be particularly important in a correctional setting, where women tend to have a heightened sense of fear and mistrust (Owen, 1998
). Yet, it is difficult to measure “environmental” qualities of a GRT program, especially within a correctional setting, where security is the priority.
Overall treatment satisfaction, a sense of safety and comfort, and a supportive peer environment may have created an increase in adherence to treatment and recovery, which may have led to reductions in drug use, increased retention in aftercare treatment, and reductions in reincarceration. However, it is difficult to untangle the specific effects of the GRT from participation in aftercare treatment. It is possible that length of time spent in residential aftercare was primarily responsible for subsequent reductions in reincarceration.
The large body of literature on the specific needs of women offenders is overwhelmingly consistent and implies a need for GRT as a potentially more effective way to facilitate their recovery. Yet, there has been a lack of empirical studies to support these beliefs, particularly experimental studies that apply rigorous controls. For practical and ethical reasons, random assignment of participants to either a treatment or control group is rare in evaluations of correctional programs.
The primary strength of this study's design was the use of random assignment, allowing all participants to receive at least the standard treatment, with some participants receiving enhanced treatment designed specifically for women offenders. This rigorous design strengthens the internal validity of our findings, and thus there is a reasonable probability that the differences detected are suitable for guiding policy recommendations. The study was further strengthened by the large percentage of women who met DSM-IV criteria for Substance Use Disorder, inclusion of a standard treatment control group, standardized instruments, two post-prison follow-up time points assessing behavioral change, and use of official records and self-report.
There were limitations to the study design as well. Quantitative fidelity measures were not implemented during the active treatment phase. Low fidelity to the curricula may significantly affect any measured outcomes by reducing the potential effects of the intervention. Also, the “usual care” group was not a “no treatment” group. Thus, the differences between groups were possibly minimized. For example, both groups showed improvement in their psychological functioning over time, which may be a result of the positive reinforcement provided by a therapeutic environment overall. Additionally, the sample size in this pilot study may not have been large enough to provide sufficient power to detect differences for some of the outcomes at the conventional .05 level, especially with regard to the relatively small effects that are typically found in correctional substance abuse treatment programs (Pearson & Lipton, 1999
). It is highly likely that a larger sample size and higher retention rates might have provided enough power to detect differences at the .05 level. Finally, the study findings are specific to the population from which the sample was derived, i.e., women offenders (primarily felons) in prison-based substance abuse treatment programs in California, and hence may not be generalizable to other populations or correctional settings.
Key Recommendations for Future Research and Program Implementation
Improving GRT Research
Since published data influence funding directions as well as public perceptions of treatment for women, the lack of rigorous science on specific treatment approaches for women offenders can effectively exclude their interests from critically important policy decisions. Further experimental studies are needed to continue to address the gap in knowledge regarding substance abuse treatment for women offenders in general and by providing specific information on the types of services and approaches that should be emphasized when treating women in prison. For example, future studies should focus on the specific components of GRT that may be related to improved outcomes or identify measures (or specify domains) that underlie and sustain change over time, such as retention in aftercare and continuity of care, improved relationships with children, better living situations, improved mental and physical health, and greater economic status.
Overcoming Barriers to Implementation
There are a number of implementation challenges when integrating a GRT program within an institution. To improve the ability to implement this type of program within a correctional setting, there needs to be ongoing staff training, technical assistance, and monitoring of adherence to the protocol. Future studies would benefit from a quantitative fidelity measure for the specific curriculum being delivered. Program facilitators would also benefit from specific training on how to deliver quality treatment in large group settings, such as breaking down into smaller groups of 5 or 6 women to increase comfort and safety when sharing. Furthermore, programming hours in prison are often limited or interrupted by security issues such as “lock downs.” One solution to such interruptions is invested training for peer mentors of core curricula, which would enable women to continue their treatment exercises when restricted to their housing units.
The finding that the GRT program was associated with reductions in reincarceration provides important information for criminal justice agencies with regard to effective rehabilitation. One can speculate that providing GRT may be more costly than standard treatment initially, with regard to curriculum materials, technical assistance, and specific training needs. Yet, reducing recidivism by delivering appropriate services provides a large benefit in future expenditures for the criminal justice system and, potentially, the child-welfare system. There are also viable alternatives to the use of incarceration for drug-related offenses. Diversion programs providing necessary services in residential community facilities are a practical and cost-effective alternative to incarceration (Oser, Knudsen, Staton-Tindall, & Leukefeld, 2009