|Home | About | Journals | Submit | Contact Us | Français|
This systematic review was conducted to more fully analyze qualitative research findings relating to community-based court-supervised substance abuse treatment for women and to make recommendations regarding treatment enhancement. Five reports of qualitative research met the inclusion criteria. Findings from these reports were extracted and analyzed using constant comparative methods. Women who are referred to court-sanctioned substance abuse treatment programs may initially be reluctant to participate. Once engaged, however, they advocate for a full complement of well-financed comprehensive services. To optimize treatment effectiveness, women recommend gender-specific programs in which ambivalence is diminished, hope is instilled, and care is individualized.
In 2009, over 5 million individuals in the United States were under correctional supervision in community settings. Of that number, over 1 million were women, a number that has doubled since 1990. These women, who are the focus of this systematic review, function under the jurisdiction of the criminal justice system, but they are not held within high-security prisons or jails (Glaze, 2010).
Unlike men, most women who are under correctional supervision in the community have not been involved in violent crimes. Instead, their offences are most often related to property and sex crimes and illegal drug use (Stalans, 2009). In keeping with these types of infractions, approximately 60% of women who are involved in community-based criminal justice systems have alcohol and drug problems (Grella, 2008; Shaffer, Hartman, & Listwan, 2009). Although exact numbers vary, similar circumstances are known to exist in countries such as the United Kingdom (Simpson & McNulty, 2008).
Women in the criminal justice system who have abused substances are perceived to have problems that differ from those of men in similar situations. In addition to the differences that have already been noted, women are more likely than men to have experienced substantive psychological and physical abuse, and they are more likely than their male counterparts to have co-occurring mood and anxiety disorders. Despite these added challenges, women are more likely than men to maintain contact and responsibility for their children (Grella, 2008; Shaffer et al., 2009).
Given these differences, gender-specific substance abuse treatment has been advocated for women since the early 1990s (Greenfield et al., 2007; Grella, 2008; Shaffer et al., 2009). Currently, an eclectic array of integrated treatment strategies that incorporate empowerment and peer support plus well-coordinated and comprehensive community services are recommended for women that are under the purview of the community criminal justice system (Adams, Leukefeld, & Peden, 2008; Grella, 2008).
Despite continual efforts to customize and perfect substance abuse treatment for women in community-based criminal justice programs; imperfections exist, and recidivism remains unacceptably high. For this reason, efforts are needed to more clearly determine what treatment strategies are most effective and why, and conversely, what treatment efforts are not working and why not (Adams et al., 2008; Scroggins & Malley, 2010; Shaffer et al., 2009). Thus, the purpose of this systematic review was to more fully explicate therapeutic attributes of substance abuse treatment programs for non-incarcerated women who are referred for help through the criminal justice system.
Qualitative methods were used to conduct this systematic review. Purposeful sampling was carried out followed by the extraction of qualitative findings (i.e., data). These data were subsequently analyzed using a constant comparative process and iterative memoing (Corbin & Strauss, 2008). Newly articulated insights, that were well-grounded in the data, were explicated.
Data for this investigation was comprised of published qualitative research findings relating to therapeutic attributes of substance abuse treatment programs for non-incarcerated women who are referred for help through the criminal justice system. To locate qualitative study reports that were congruent with this area of investigation, a professional reference librarian designed and conducted searches of relevant electronic databases. To take full advantage of specialized databases, customized strategies were used to search each one (e.g., Table 1). In alphabetical order, the academic and government databases that were searched include: Criminal Justice Abstracts, ETOH Archival Database, National Criminal Justice Reference Service, MEDLINE, ProQuest Dissertations and Theses Database, PsycINFO, PubMed, Social Services Abstracts, and Social Work Abstracts.
Searching was ongoing until data analysis was complete in March 2011. A strictly imposed historical cutoff date for searching was not deemed necessary since the gender-specific treatment programs of interest are relatively new, and inclusion of obsolete findings was not considered a substantive threat to validity. Expansive searching of the English language literature continued until all available and applicable databases were explored, and no new references were found that met the inclusion criteria.
Searching the literature resulted in over 2,600 citations, with some unavoidable duplication across databases. Documents were excluded from further consideration if they were not reports of qualitative research, and/or they were not consistent with the topic under investigation. Examples of the latter include studies in which treatment occurred while women were incarcerated; substance abuse was not the focus of treatment; men, adolescents, and/or children constituted the sample; and/or findings pertaining to adult women could not be isolated from those pertaining to men, adolescents, or children. Since the topic for this systematic review was well-defined from the outset, there was little, if any, debate about which reports met the inclusion criteria. In most instances, reports that were excluded met multiple exclusion criteria.
The five reports that met the study inclusion criteria were carefully read, and qualitative findings (i.e., data) relating to attributes of treatment were extracted and entered into an electronic data analysis matrix. Once data extraction was complete, analysis proceeded using a constant-comparison process. Findings (i.e., data) with similar meaning were systematically grouped together, and descriptive memos were developed. Constant comparison continued in an iterative manner, and explanatory memos were revised until substantive ideas were categorized and fully explicated (Corbin & Strauss, 2008).
Original studies that comprised the sample for this investigation were not evaluated for quality in their entirety. Rather, the validity of extracted findings was assessed based on their fittingness (Lincoln & Guba, 1985) on two separate occasions; first, within the context of the studies from which they were extracted, and second, within the context of the memos in which they were systematically integrated and explicated (Pawson, 2006). Initially, findings that were contextually supported by thick description were deemed valid and extracted for analysis. In the latter case, contextual congruency and fittingness of the findings were assessed in a constant-comparative manner throughout the data analysis and memoing processes (Lincoln & Guba, 1985).
Five reports of qualitative research that were published from 2006 to 2009 comprised the sample for this investigation (see Table 2). Two were published as dissertations (Kerr, 2009; Mastrorilli, 2008), and the remaining three appeared in peer-reviewed journals (Fischer, Geiger, & Hughes, 2007; McKim, 2008; Sowards, O’Boyle, & Weissman, 2006). In keeping with the aim of this review, the purpose of these investigations was to examine the attributes of substance abuse programs that were specifically designed for women who were referred through the criminal justice system to participate in treatment outside of high-security prisons or jails.
One program was classified as a drug court and served as an alternative to incarceration (Fischer et al., 2007). Two were community-based outpatient programs that provided services for women who were mandated to participate in treatment through the criminal justice system. Some participants were probationers or parolees; others took part as an alternative to incarceration (Kerr, 2009; Sowards et al., 2006). A third program was residential, and women enrolled as an alternative to incarceration or as a condition of their parole (McKim, 2008). A final substance abuse treatment program was located in a community-based low-security facility. This program was designed to provide re-entry services for women who were formerly incarcerated, and participants were allowed to leave to go to work (Mastrorilli, 2008).
All of the programs were located in the United States, 3 in the northeast (Mastrorilli, 2008; McKim, 2008; Sowards et al., 2006), 1 in northern California (Fischer et al., 2007), and the other in an undisclosed location (Kerr, 2009). Each program included supervision and monitoring through a law-enforcement or correctional system as well as a wide variety of therapeutic services. Common among them was a focus on abstinence, personal growth, acquisition of adaptive life skills, vocational training, healthy relationships, and employment. Program length was not clearly defined in all instances, but it appeared to range anywhere from 3 months to 2 years.
Four programs were investigated using a qualitative research design; one was studied using a mixed-methods approach (Mastrorilli, 2008). Three investigations were informed by one or more research theoretical frameworks, including relational theory (n = 2), trauma theory (n = 1), addictions theory (n = 1), and ethnography (n = 1). In two cases, a research theoretical framework was not identified (Fischer et al., 2007; Sowards et al., 2006). Several data collection methods were used across the studies, including one-on-one interviews; focus groups; and participant observation of individuals, staff meetings, client groups, and informal client gatherings. In the context of systematic reviews, these types of theoretical and methodological variations across original studies are thought to constitute a form of triangulation that increases the validity of review findings (Finfgeld-Connett, 2010).
Due to concerns about anonymity within small context-rich samples, qualitative reports frequently do not include comprehensive demographic information (Morse, 2007, 2008). This was the case with two of the five studies included in this systematic review. Given the information available, it appears that a minimum of 70 respondents (63 clients; 7 staff) participated across all five of the original investigations. Of this number, data were collected from no less than 24 Whites, 12 African-Americans, and 3 Hispanics. Based on information provided within three of the five study reports, the mean ages of the participants ranged from 34 to 44.
Women who are referred to court-sanctioned substance abuse treatment programs in the community may initially be reluctant to participate. Once they are engaged, however, they advocate for a full complement of well-financed comprehensive services. To optimize the effectiveness of these services, women recommend gender-specific programs in which hope is instilled and individualized care is provided. These findings are discussed in greater depth in the remainder of this article.
Women who are court-referred to participate in substance abuse treatment programs may initially be reluctant to engage (Sowards et al., 2006), and they must reach a critical level of readiness before they can take full advantage of the services that are available. It is necessary for them to be committed to ending an ongoing cycle of substance abuse, crime, and incarceration that has become their life motif. In particular, they must admit their problems, assume responsibility, and be active participants in their own rehabilitation (Fischer et al., 2007; Kerr, 2009; Mastrorilli, 2008).
The reality for many women who are part of the law-enforcement/correctional system is that substance abuse treatment is an alternative to incarceration, and at least initially, treatment could simply be viewed as the lesser of two evils. In addition, many of these women have participated in substance abuse programs before, and they may not believe that therapeutic efforts can help them. Others may feel unworthy of assistance due to social stigma and interpersonal abuse that they have experienced throughout their lives. Still others may be reluctant to seek or accept help due to shame associated with things that they have done in the past (Sowards et al., 2006).
Consequently, enthusiasm for treatment may only develop with time if women perceive that they are in a safe and caring environment and that the system is able to meet their needs (Fischer et al., 2007; Mastrorilli, 2008).
To this end, the treatment community is urged to offer accessible, coordinated, and comprehensive services to women who are referred to participate in substance abuse treatment through the criminal justice system. Using a checklist approach, women recommend individual and group counseling, twelve-step programs, opportunities to develop life skills, vocational training, and job placement (Fischer et al., 2007; Kerr, 2009).
In addition to this list of services, women also acknowledge the importance of having access to family throughout the treatment process. For the short-term at least, they perceive that it is therapeutic for them to establish, re-establish, and/or maintain healthy relationships with family and friends in protected or supportive circumstances (Kerr, 2009; Mastrorilli, 2008). For example, as women enter treatment, child-compatible residential centers are recommended. Later, as women move toward vocational training or work, daycare services are seen as more relevant to their circumstances (Fischer et al., 2007; Kerr, 2009).
Although easy to enumerate, therapeutic execution of these services may be challenging, especially when clients must move toward a critical level of readiness prior to maximizing therapeutic effectiveness (Fischer et al., 2007; Kerr, 2009; Mastrorilli, 2008). In addition, women’s lives may be complicated by the fact that they must focus on abstinence while simultaneously attending to parenting and childcare, educational goals, and job placement (Mastrorilli, 2008; McKim, 2008). The remainder of the findings from this investigation relate to how treatment efforts can be optimized to most effectively meet the needs of these women.
Given that many women are not fully motivated when they enter corrections-based substance abuse treatment programs, and personal motivation is perceived as an important precursor to treatment success; efforts to initially enhance participants’ motivation are perceived to be important treatment priorities. As such, it is recommended that, from the start, treatment staff instill hope by communicating to participants that they have the potential to change (Mastrorilli, 2008). Moreover, as treatment progresses, staff are encouraged to incrementally acknowledge and reward participants for small successes (Fischer et al., 2007).
It is perceived that hope is inspired within all-women treatment programs. Women indicate that they become motivated when they see individuals like themselves who have been able to overcome obstacles and change their lives for the better. Peer role models help them to diminish shame and foster hope that treatment, and the system in general, can help them alter their lives for the better (Sowards et al., 2006).
Surrounded by women, co-participants profess the ability to reach a level of trust that allows them to be introspective and speak openly about physical and psychological abuse. They are also allowed the freedom to offer honest feedback, mutual understanding, affirmation, and support. This type of engagement is particularly important for adult women who may be learning about healthy interpersonal relationships, effective communication, and socially-adaptive behavior for the first time (Kerr, 2009; McKim, 2008; Mastrorilli, 2008).
Women who have been engaged to participate in substance abuse treatment through the justice system suggest that in order for services to be therapeutic, they must be tailored to meet the needs of the individual (Kerr, 2009; Mastrorilli, 2008). A one-size-fits-all approach is not perceived to work for the duration, and continual personalization, problem solving, and course corrections are needed (Fischer et al., 2007; Kerr, 2009; Mastrorilli, 2008). To successfully execute this complex process and to promote accountability, women advocate for a voice in treatment planning and continual assessment and reassessment of treatment and supervision needs. To this end, women advocate for strong and enduring alliances with staff, even after justice-mediated commitments have been met (Kerr, 2009; Mastrorilli, 2008).
Women expect to encounter challenges throughout the treatment process (Kerr, 2009; Mastrorilli, 2008). For this reason, they are not patently averse to intensive supervision, criticism, and corrective sanctions as long as these measures are imposed fairly and for the purpose of education rather than punishment or humiliation. Women report that one of the most salient components of treatment is the presence of caring individuals who treat them with dignity and respect and who are genuinely interested in their progress (Fischer et al., 2007; Mastrorilli, 2008).
Creation of this type of therapeutic rapport is perceived to be possible when treatment personnel; including judges, parole officers, mental health professionals, and security officers are knowledgeable about the recovery process. In addition, it is recommended that at least some of these individuals understand their clients’ situations from a personal perspective. For instance, women counselors and former women addicts are perceived as optimally qualified to empathize and be therapeutic because they have had similar experiences (Fischer et al., 2007).
In lieu of an all-female staff, male employees are urged to be good role models and to provide participants with adaptive interpersonal learning experiences. They are asked to adhere to program guidelines and maintain professional boundaries while simultaneously demonstrating understanding and empathy. These therapeutic care requisites are perceived to be particularly important during hours of the day and night when clients’ needs may be great, and staffing may be low (Fischer et al., 2007; Kerr, 2009; Mastrorilli, 2008).
Awareness of the cost of optimal treatment for women who are linked to the justice system is evident within the qualitative research findings (Fischer et al., 2007; Kerr, 2009; Mastrorilli, 2008). Staff-client relationships such as those recommended within the literature come at a relatively high staff-to-participant ratio. In addition, women with criminal records may find it difficult to pay for vocational training and to secure jobs (Fischer et al., 2007). For these reasons, financial commitment to community-based treatment programs that are linked to the correctional system appears fundamental to their success (Fischer et al., 2007; Kerr, 2009; Mastrorilli, 2008).
Several types of treatment success go hand-in-hand with sustained abstinence (Fischer et al., 2007). Among these are increased self-awareness; self-esteem; and confidence in one’s abilities to make good decisions, function within adaptive boundaries, and renegotiate unhealthy relationships. Personal empowerment is enhanced so that individuals are better able to participate in educational opportunities, find and maintain jobs, gain or regain healthy relationships, and participate in community activities (Fischer, 2007; Kerr, 2009; Mastrorilli, 2008). Similar to women without criminal justice backgrounds, formerly incarcerated women hope to achieve reasonably happy and meaningful lives (Fischer, 2007). To attain this ideal, sustained support from therapeutic entities within the criminal justice system (Mastrorilli, 2008) and ongoing access to mental health care may be required (Kerr, 2009).
Within the research literature, support for well-financed, accessible, comprehensive, gender-based substance abuse services for women in the criminal justice system is well-documented (Adams et al., 2008; Grella, 2008; Kassebaum, 1999; Scroggins & Malley, 2010; Simpson & McNulty, 2008). What are less well documented and supported are the interpersonal aspects of treatment that emerged from this systematic review. Based on findings from this investigation; attributes of treatment that may require new or renewed attention include diminishment of client ambivalence, instillation of hope, trust-based provider-client relationships, individualized care, and the establishment and maintenance of personal dignity and respect.
These findings are similar to recommendations that have been made in other areas of healthcare. For example, in acute care settings, providers are being asked to assess and communicate with patients using back-to-basics methods: eye-to-eye contact, hand-to-skin assessments, and empathic-voice-to-anxious-ear interactions (Verghese, 2008, 2011). In effect, patients/clients appear to be asking for personalized care, opportunities to hope and trust, and attainment and preservation of personal integrity across treatment settings. Of particular interest in terms of future research and practice, is how these types of treatment attributes can be implemented and sustained in highly complex and demanding clinical settings over time.
It is noteworthy that evidence-based motivational interventions (Miller & Rose, 2009) did not appear to be a part of the substance abuse treatment programs that were described in the reports that comprised the sample for this systematic review. The absence of this type of therapeutic intervention seems particularly relevant given the high level of ambivalence that women within the criminal justice system appear to have prior to entering and fully participating in community-based substance abuse treatment programs. In the future, it is recommended that researchers evaluate the potential effectiveness of intervention strategies such as motivational interviewing in this treatment context.
Although length of treatment varied greatly (3 to 24 months) among the programs that were studied, time enrolled was not identified as a relevant factor in terms of treatment success. Instead, what was articulated to be important was intermittent and ongoing access to supportive treatment personnel after formal programming was over. This finding is relevant in terms of the potential for less costly long-term follow-up services.
A relatively small number of reports of qualitative research met the inclusion criteria for this systematic review. It is also notable that all of the studies that constituted the database were conducted in the United States (US). Thus, it cannot be assumed that the findings are fully intra- or internationally generalizable. For comparative purposes, the execution of US and non-US-based qualitative investigations of the type included in this systematic review are recommended.
Given the need for court-supervised substance abuse treatment programs for women in the community and the limited resources that are available to support such enterprises, it is important to maximize their effectiveness. Based on insights that were generated from this systematic review, it appears that diminishing client ambivalence, instilling hope, establishing trust-based provider-client relationships, individualizing treatment, and establishing and maintaining personal dignity and respect are key ways to enhance treatment effectiveness. In addition, it is inferred that integrating motivational interventions into treatment protocols has the potential to enhance the effectiveness of existing treatment strategies.
Funding: The project described was supported by Grant Number R21DA024749 from the National Institute on Drug Abuse. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Declaration of Interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Deborah Finfgeld-Connett, S321Sinclair School of Nursing, University of Missouri, Columbia, Missouri, USA, 65211, Telephone: 573-884-7255, Fax: 573-449-6632.
E. Diane Johnson, Information Services and Resources, J. Otto Lottes Health Sciences Library, University of Missouri.